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[ { "category": "Radiology", "chartdate": "2103-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 828302, "text": " 12:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ETT position and R Lung s/p RUL/RML biopsy\n Admitting Diagnosis: IDIOPATHIC PULMONARY FIBROSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with h/o pulmonary fibrosis\n\n REASON FOR THIS EXAMINATION:\n assess ETT position and R Lung s/p RUL/RML biopsy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 83 y/o woman with pulmonary fibrosis. Endotracheal tube\n placement.\n\n PORTABLE AP CHEST: Comparison is made to previous films from 3:46 a.m.. The\n patient is status post lung biopsy in the right middle and lower lobes. The\n right chest tube is seen overlying the right hemithorax. No pneumothorax is\n identified. The tip of the endotracheal tube is identified 3 cm above the\n carina. Again note is made of underlying diffuse lung disease.\n\n IMPRESSION: No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2103-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 828498, "text": " 11:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: asses for change after diuresis\n Admitting Diagnosis: IDIOPATHIC PULMONARY FIBROSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with h/o pulmonary fibrosis s/p VATS and lung bx on R\n\n REASON FOR THIS EXAMINATION:\n PLEASE DO THIS FILM AFTER 10AM.assess for change after diuresis. Check for PTX\n s/p R chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 83-year-old with a history of pulmonary fibrosis post VATS,\n\n PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH\n\n COMPARISON: and .\n\n Again are seen persistent bilateral interstitial markings. There appears to\n have been, however, a slight improvement in interstitial markings in the upper\n zones suggesting the possibility of improving superimposed congestive heart\n failure. There is improved aeration at the left lung base. Bilateral\n atelectatic changes and small pleural effusions are still present. A right-\n sided chest tube is unchanged in position. There is no pneumothorax. There\n has been interval extubation and removal of an NG tube.\n\n IMPRESSION: Improved aeration at the left lung base. Slight improvement in\n interstitial markings in the upper zones suggests an element of improving\n congestive heart failure upon a background of diffuse pulmonary fibrosis.\n Persistent bibasilar atelectasis and small effusions. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2103-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 828593, "text": " 5:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Effusions?\n Admitting Diagnosis: IDIOPATHIC PULMONARY FIBROSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with h/o pulmonary fibrosis s/p VATS and lung bx on R.\n Patient now extubated.\n REASON FOR THIS EXAMINATION:\n Effusions?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83 y/o with pulmonary fibrosis post VATS.\n\n PORTABLE SUPINE FRONTAL RADIOGRAPH. Comparison and .\n\n There has been interval removal of a right sided chest tube. There is likely a\n very minimal lateral right pneumothorax. There has been interval development\n of bibasilar patchy opacities. Interstitial markings are essentially unchanged\n allowing for positional differences. Cardiac and mediastinal contours are\n unchanged. Subcutaneous air is seen overlying the lower right lateral chest\n wall.\n\n IMPRESSION: Possible small right lateral pneumothorax post chest tube removal.\n Patchy opacities at the lung bases may represent atelectasis or infiltrates.\n Background of interstitial disease is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2103-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 828381, "text": " 10:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p VATS w/pulm fibrosis-r/o effusion/infiltrate\n Admitting Diagnosis: IDIOPATHIC PULMONARY FIBROSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with h/o pulmonary fibrosis\n\n REASON FOR THIS EXAMINATION:\n s/p VATS w/pulm fibrosis-r/o effusion/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST: Compared to .\n\n INDICATION: Pulmonary fibrosis. Status post VATS procedure.\n\n Right sided chest tube, endotracheal tube and nasogastric tube remain in\n satisfactory position. No definite pneumothorax is evident on the semi-erect\n projection. The cardiac and mediastinal contours are stable. Again\n demonstrated are areas of pulmonary fibrosis bilaterally. Additionally,\n there are more confluent areas of opacity at the bases, particularly in the\n left retrocardiac region. The latter has worsened in the interval. The left\n costophrenic sulcus area is not well demonstrated and it is difficult to\n exclude a pleural effusion this region as well.\n\n IMPRESSION:\n 1) Worsening left retrocardiac opacity, which may be due to a combination of\n atelectasis and effusion. It is difficult to exclude underlying infectious\n process.\n 2) Diffuse pulmonary fibrosis.\n\n" }, { "category": "Radiology", "chartdate": "2103-06-03 00:00:00.000", "description": "P CHEST (PRE-OP AP ONLY) PORT", "row_id": 828277, "text": " 3:32 AM\n CHEST (PRE-OP AP ONLY) PORT Clip # \n Reason: baseline cxr\n Admitting Diagnosis: IDIOPATHIC PULMONARY FIBROSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with h/o pulmonary fibrosis\n REASON FOR THIS EXAMINATION:\n baseline cxr\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 83-year-old woman with history of pulmonary fibrosis.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed. No previous study\n is available for comparison.\n\n There is diffuse lung disease with a somewhat peripheral and basilar\n distribution with probable honeycombing. These findings are consistent with\n the patient's history of pulmonary fibrosis. The differential diagnosis could\n include NSIP, sarcoidosis, or chronic hypersensitivity pneumonitis.\n\n The heart and mediastinum are within normal limits. No pneumothorax is\n identified.\n\n" }, { "category": "Radiology", "chartdate": "2103-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 828311, "text": " 3:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS OGT POSITION\n Admitting Diagnosis: IDIOPATHIC PULMONARY FIBROSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman S/P OGT PLACEMENT\n REASON FOR THIS EXAMINATION:\n ASSESS OGT POSITION\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, 1 VIEW, PORTABLE:\n\n INDICATION: 83 year old woman status post NGT placement.\n\n COMMENT: Portable AP radiograph of the chest is reviewed, and compared to the\n previous study of 3:46 A.M.\n\n The patient is probably status post biopsy of the lung. A chest tube is seen\n overlying the right hemithorax. There is no evidence of a pneumothorax. The\n tip of the ETT is identified 3 cm above the carina. Again note is made of\n underlying diffuse lung disease.\n\n There is new NGT coursing toward the stomach.\n\n IMPRESSION:\n 1) A NGT courses toward the stomach. No pneumothorax.\n\n" }, { "category": "Echo", "chartdate": "2103-06-05 00:00:00.000", "description": "Report", "row_id": 77481, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 65\nWeight (lb): 240\nBSA (m2): 2.14 m2\nBP (mm Hg): 127/54\nHR (bpm): 59\nStatus: Inpatient\nDate/Time: at 12:10\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nThere is severe global left ventricular hypokinesis. There is no resting left\nventricular outflow tract obstruction.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. There is mild\nglobal right ventricular free wall hypokinesis.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets appear structurally normal with good\nleaflet excursion. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is mild\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a low risk (prophylaxis not recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is severe global left ventricular hypokinesis.\nRegional function cannot be fully assessed. Right ventricular chamber size is\nnormal. There is mild global right ventricular free wall hypokinesis. The\naortic valve leaflets appear structurally normal with good leaflet excursion.\nTrace aortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic\npressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Severe global hypokinesis c/w diffuse process (toxin, metabolic,\nmultivessel CAD, etc.). Mild mitral regurgitation.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2103-06-04 00:00:00.000", "description": "Report", "row_id": 1364738, "text": "Nursing Note:\n\nREVIEW OF SYSTEMS:\n\nCV: Hemodynamic status stable, hr=55-60, SB, occ. pvc, bp=139-170/50-60, ext. warm, + dp bil., k=3.0, repeat on serum 4.2, continues with t-wave inversions.\n\nRESP: Weaned to IMV 6, changed to PS 10, 5 peep with decreasing sat=88%, PS increased to 10, 5 peep, fio2=60, seems comfortable on PS 10, 5 peep, sat=95%, propofol infusing at 30 mcg/kg/, with attempted wean to 20, pt. becomes hypertensive, and desaturates. Crackles l. base, suctioned for thick blood tinged sputum.\n\nGI: Abd. soft, hypoactive BS, 200cc gastric drainage, prevacid started, hypoactive BS, abd. soft,\n\nGU: Foley to gravity, u/o= 30cc/hr, iv fluid decreased to 40cc/hr\n\nSKIN: Ext. edematous, ecchymotic area at insertion site iv r. upper arm, erythema at insertion site iv left lower arm. Back intact\n\nID: Continues on Levofloxin\n\nENDO: Insulin drip titrated as per protocol\n\nMENTATION: Follows commands when propofol decreased, moves all ext., writing notes to family, recognizes family. Medicated with mso4 2mg for incisional discomfort.\n\nSOCIAL: Sons and daughter in to visit, asking many questions about the breathing tube, plans for ext., anxious to talk to MD regarding status. Pt. writing notes to family.\n\nPLAN: Continue with pul. toilet, ? resume antihyptensives, ? diuresis, continue to titrate insulin as per BS, replete lytes as needed. Provide support to family.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-04 00:00:00.000", "description": "Report", "row_id": 1364739, "text": "Respiratory Care Note:\n Patient continues on PSV this afternoon. She failed earlier weaning attempts of with decreased SpO2 around 88%. Support was increased with good effect. BS with crackles bilat bases, no wheezing. Suctioned for med amount of thick bloody secretions. She is receiving combivent MDI Q6. Plan to maintain at this time. Also noted that she is being managed by MICU service.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-04 00:00:00.000", "description": "Report", "row_id": 1364740, "text": "NEURO: SEDATED WITH IV PROPOFOL, INTERACTS WELL, ASKING TO BE GIVEN MORE SEDATION SO THAT SHE CAN SLEEP. MEDICATED WITH IV MS PAIN WITH RELIEF.\nCARDIAC: MP SB TO SR WITHOUT ECTOPY. POTASSIUM REPLEATED. ANTIHYPERTENSIVES RESTARTED WITH EFFECT.\nRESP: CS DIMINISHED IN AM, SUCTIONED FOR THICK BLDY, SMALL AMTS. HOPE TO EXTUBATE IN AM. CT FOR SMALL AMT SER-SANG DRAINAGE, NO , NO CREPITUS.\nGI: OG IN PLACE, TUBE FDS STARTED AT 1700. PLAN TO STOP AT 0400. RESIDUALS WITHIN ACCEPTABLE LIMITS.\nGU: LASIX WITH EFFECT, WILL REDOSE IF URINE DROPS TO 50 CC QH.\nENDO: FOLLOWING PROTOCOL, LABILE GLUCOSES.\nFAMILY IN, AWARE OF PLANS.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-03 00:00:00.000", "description": "Report", "row_id": 1364733, "text": "ALTERED RESPIRATORY STATUS\nO: CARDIAC: SB 50'S WITHOUT VEA-EKG DONE, SBP 110'S TO 140'S. FEET WARM TO TOUCH. PALP PP. HCT 25 TO RECIEVE 2 UPC. LYTES PENDING.\n RESP: REMAINS INTUBATED, ABG PER FLOW - FIO2 @ 80%. BS DIMINISHED - CLEAR UPPER. O2 SAT >98%. NO CHEST TUBE LEAK. TO SLOWLY WEAN AND WORK ? REMAIN INTUBATED OVERNIGHT. CXR DONE\n NEURO: SEDATED ON 50 MCQ OF PROPOFOL. PERL.\n GI: OGT TO BE PLACED . ABD OBESE SOFT + BOWEL SOUNDS.\n GU: AMBER URINE 10 ML/HR THEREFORE TO RECIEVE 2 UPC WITH HCT 25.\n ENDO: AWAITING GLUCOSE\n ID: LEVO Q 24\n SOCIAL: SPOKE TO DAUGHTER OVER THE PHONE AND UPDATED\nA: SB, SEDATED ON PROPOFOL, SLOW WEAN\nP: MONITOR COMFORT, HR AND RYTHYM , SBP, INCISIONS, RESP STATUS- SLOW WEAN- REMAIN INTUBATED OVERNIGHT, NEURO STATUS- WEAN PROPOFOL, I+O, LABS PENDING, 2UPC, AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-03 00:00:00.000", "description": "Report", "row_id": 1364734, "text": "Resp Care\nPt received from OR and placed on SIMV/PS-parameters noted. Pt is a s/p lung biopsy for idiopathic pulmonary fibrosis. Breath sounds are coarse in upper lobes and decreased in bases. Suctioning a mod amt of blood through ET tube. Will wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-03 00:00:00.000", "description": "Report", "row_id": 1364735, "text": "Neuro: Propofol weaned and patient awake, appears alert, following commands.\nCardiac: Mp sb to sr without ectopy. Potassium repleated by 500 ns with 40 meq k at 100 qh. 2 unit cells given.\nResp: Cs coarse upper, diminished in bases, suctioned for thick old . Plan to wean and hope to extubate in am. Will remain sedated with iv propofol/ms. for small amt sero-sang drainage.\nGi: Og tube passes, chest x ray for placement done. for bilious to brown liquid.\nGu: foley in place, for amber urine, small amts, ho aware.\nEndo : Insulin gtt ^, following protocol.\nPain: medicated with iv ms with effect.\nFamily: Spoke with husband and daughter, daughter is now contact person, they plan to visit tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-04 00:00:00.000", "description": "Report", "row_id": 1364736, "text": "Respiratory Care:\nPatient was initially decreased from 60% to 50% oxygen and tolerating it well. Patient's SPO2 plummeted to 86% which did not respond to vigorous bronchial hygeine (manual breaths with lavaging and multiple instillations The FIO2 was increased to 70% and the PEEP was increased first to 7 and finally to 10 cm before some corrective numbers were displayed. Morning abg results demonstrated good oxygenation, and the FIO2 has been decreased to 50% once more with no change made to the PEEP. Results to follow.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-04 00:00:00.000", "description": "Report", "row_id": 1364737, "text": "RN progress note\nneuro: sedate on propofol gtt, prn MS. , follow commands; gets very anxious w/ sx, turning. No focal deficits.\n\nCV: SB, NSR w/ AEA, short salvo AIVR. HR 45-65. SBP 120's-140's. Palp pulses. EKG non-ischemic, flipped T's anteriorly. Cardiac enzymes drawn\n\nPulm: SIMV x 750 x .5 x most of noc w/ ABG's comparable to pre-op. Episode of de-saturation to 86% resistant to lavage/ambu/100%, finally recovered w/ increased PEEP to 10, FiO2 to 70. Presently 50%xPEEP 10 w/ adequate ABG's, SpO2 94-95. BS course throughout, crepitous superior to CT insertion. Intermittent air , CT drainage.\n\nGI: abd soft, hypo BS. OGT bilious.\n\nGU: UOP 30-50cc/hr; BUN/Cr: 69/.9\n\nMS/derm: mult eccymoses, skin intact. Coccyx sl pink. Posterior CT dsg changed for mod s/s drainage; 2 bx sites C/D.\n\nEndo: insulin gtt cont w/ spikes in BG after hydrocortizone.\n\nID: WBC 14; Tmax 99.5, po.\n\nHeme: H/H stable after post-op tx 2 UPRBC's.\n\nP: wake & wean. Vigorous bronchial hygeine. Secure CT vs d/c. CXR this am . F/U cardiac enzymes/EKG.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-05 00:00:00.000", "description": "Report", "row_id": 1364744, "text": "MICU Nursing Transfer Note\nPt transfered from CRSU at 9am. Admit on for a video thorascopic procedure for a dx of pulmonary fibrosis. During procedure increase in CP, r/o for PE was inconclusive. Lung bx showed idiopathic pulmonary fibrosis.\n\nPMH: CHF, pulmonary fibrosis, hypercholes, HTN, depression, past hip replcmnt.\n\nAllergies: procardia (palpitations), Voltaven (syncope)\n\nNeuro: A&O x3, propofol weaned last night in CRSU.\n\nResp: Extubated upon arrival, now on hi-flow hum FT at 95%. sats 95%-96%. RR 14-16. Secretions previous to extubation thick and moderate amt dark blood. Pt coughing up secretions and using yank at will. R post chest tube to water seal, no air seen. CT drsg and . 2- 2x2 drsgs to biopsy sites dry and .\n\nCV: HR 58-65. NSB-NSR with occas PVC's. BP 140/53.\n\nGI: OGT d/c'd with ET tube. tolerating ice chips. Hypoactive BS. Soft, obese abdomen.\n\nGU: Foley in place, drg clear, yellow urine.\n\nEndo: Insulin gtt dc'd at 8am due to BS at 78.\n\nFamily: Lives with husband. Four grown children. Pt thinks husband will be in today. Message left on home machine that pt trsfrd here.\n\nPlan: Continue hourly BS, advance diet as tolerated, continue humdified FT for 1-2 hours, monitor for laryngeal edema, check post extubation blood gas and x-ray, offer reassurance, monitor I&O, monitor CT for air .\n" }, { "category": "Nursing/other", "chartdate": "2103-06-05 00:00:00.000", "description": "Report", "row_id": 1364745, "text": "MICU Nursing Update Note 7a-7p\nPt tolerating extubation well. Approximately 12 noon she experienced a sharp chest pain on Lower right side that lasted approx 1 and then became a dull, pain worsened with inspiration. Approx 5 later pain subsided. Pt now feels dull pain with very deep inspiration. EKG performed at time.\n\nNeuro: a & o x3\n\nResp: Now on 6L NC and sats 90-93% at rest. 89-90% with talking. Face tent dc'd. sputum sample sent. Continues to cough up blood tinged sputum, at times with mod amt dark blood. R post chest tube to water seal, no air seen, drsg and . 2- 2x2 drsgs on biopsy sites near CT entrance are dry and . 1800 CT surgery in an D/C'ed CT. Pt medicated with 2mg MSO4 for the procedure.\n\nCV: HR NSR-NSB with occas PVC's. BP 140's-150's/50's-60's\n\nGI: + BS, soft, obese abdomen, no BM this shift. Tolerating juice and awaiting soup for dinner. Started on low sodium diet. Tolerating PO meds.\n\nGU/Input/Output: Drg clear yellow urine in foley. Given 60mg IV Lasix at 1715.\n\nEndo: started on QID sliding scale insulin and FS. covered with 2U regular at 4pm for BS of 155.\n\nFamily: Husband, children and grandchildren have been in and out all day. Very supportive. Most of them commuting from .\n\nPlan: Induced sputum scheduled for the morning. Advance diet as tolerated, monitor resp status for S&S of pneumothorax, continue to monitor blood sugars as diet advances.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-05 00:00:00.000", "description": "Report", "row_id": 1364741, "text": "Update\nO: CV status:sbrady-nsr w occ pvc's. sbp @ rest 85-90 propofol wean dwn sbp^. While awake sbp 100-150 range.Skin and dry. Distal pulses palp\n\nResp status: rested overnight on 10ps5peep &fio2 50% w marginal o2sats 88-92%. Early am decr to after propofol off w sats ^93-95%. Lavage and suct several times overnight for thick bldy to bl tinged sputum. Bbs clear after suctioned,slt diminshed at bases. pl ct to -20 suc w sm ss drng and no air noted.\n\nNeuro status: Sedate on propofol 30, awake and anxious w propofol wean to 20mcg/kg. Med x 2 for pt c/o pain w mso4 2 mg. Pt still c/o some pain pupils pinpt though and pt nodding off occas. Explained to pt concern re: oversedation delaying extub and pt agreed discomf tolerable until ett out.Mae spont and to command. Calms w freq verbal reassurance and nurse at all times.\n\nGi status: Respalor at 10 tol well. Dc'd tf at 0400 for plan extub.\nEndocrine: insulin gtt continues at 10u/hr w gd glucose control\n\nGu status: uop's bdline to <30cc/hr w sbp <90. Adeq uop w improved sbp clear yellow urine.\n\nHeme/Id: afebrile,hcts stable last pm. am labs not drawn yet per orders due at 0600.\n\nA/P: Adeq sats, rsbi,rr on cpap.Check abg w am labs.? anxiolytic atc.Follow glucoses and cont titrate gtt.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-05 00:00:00.000", "description": "Report", "row_id": 1364742, "text": "Respiratory Care:\nPatient was lowered to CPAP, 50% 5-PSV/5-PEEPat approximately 4:40 am. At 5:00 am RSBI was measured and found to be 42.8 and an SBT was initiated using 5 PSV, 0-PEEP and 50% O2. Tolerating this well. ABG results revealed a mild mixed alkalemia with good oxygenation, based upon the patient's history. Continuing SBT. The plan is to extubate this am.\n" }, { "category": "Nursing/other", "chartdate": "2103-06-05 00:00:00.000", "description": "Report", "row_id": 1364743, "text": "PROB: TRANSFER TO MICU-A\n\nCV: SB-SR WITH PVCS, VSS. CT CHANGED TO WATER SEAL PER DR. . CT DRAINING SMALL AMOUNT OF S/S DRAINAGE.\n\nRESP: LUNGS CLEAR. SUCTION FOR BLOOD TINGED SPUTUM. O2 SATS 92%.\n\nGU: UOP CLEAR YELLOW.\n\nGI: BOWEL SOUNDS PRESENT. ABD SOFT, OBESE.\n\nENDO: INSULIN DRIP CONT., SEE FLOW SHEET/\n\nNEURO: , , NODS APPROPRIATELY.\n\nASSESSMENT: READY TO EXTUBATE.\n\nPLAN: TRANSFER TO MIC=A\nREADY TO EXTUBATE PER DR. \n" }, { "category": "Nursing/other", "chartdate": "2103-06-06 00:00:00.000", "description": "Report", "row_id": 1364746, "text": "Nursing NPN 7pm-7pm\n\nEvents: No major events overnoc. Pt continues to do well with extubation although she does desat quickly to low 80's without supplemental O2 (home O2 dependent 6L). Received serax for sleep. Hemodynamically stable. See carevue for all objective data.\n\nNeuro: AA&Ox3. pleasant and cooperative. Pt received serax for sleep and slept on and off throughout the night. Pt expressed anxiety around health care issues but easily calmed with explanation and reassurance. Pt has h/o depression. Pt to restart on zoloft in am.\n\nResp: Initially pt on both aeresol mask @ 95% fio2 and NC @ 6L. Pt asked to be placed on on face mask while she slept. pt placed on face mask 10L with good O2 sats 91-96%. LS CTA. Pt with strong cough. Receiving inhalers as ordered although pt's lungs with no wheezes. Old CT dressing site remains with no drainage. Pt need new req for Induced sputum that was ordered for this am.\n\nCV: hemodynamically stable. HR 61-71, NSR c rare PVCs. pm K 3.7. Pt treated c 40meqkcl po. Am K 4.4. Hct 30.9. Pt has 1 peripheral IV which is and flushing without problems.\n\nGI: diet advanced to low NA as tolerated. Taking liquids without difficulty. ABd. soft, non tender. BS present. no stool this shift.\n\nGU: Good u/o 50-400cc/hr. Pt-200cc LOS.\n\nEndo: QID RISS.\n\nDispo: Remain in MICU. Full code.\n" }, { "category": "ECG", "chartdate": "2103-06-05 00:00:00.000", "description": "Report", "row_id": 189435, "text": "Sinus bradycardia. Left bundle-branch block. Technically limited study with\nwandering baseline in leads V4-V6. Compared to the previous tracing of \nno apparent diagnostic interim change. However, a repeat tracing of diagnostic\nquality is suggested.\n\n" }, { "category": "ECG", "chartdate": "2103-06-03 00:00:00.000", "description": "Report", "row_id": 189436, "text": "Sinus bradycardia\nLeft bundle branch block\n\n" } ]

[ { "category": "Radiology", "chartdate": "2150-06-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969511, "text": " 11:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval position of the ETT and eval for acute cardiopul\n Admitting Diagnosis: HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man found down brought to the OSH hypoglycemic, ? aspiration,\n intubated\n REASON FOR THIS EXAMINATION:\n please eval position of the ETT and eval for acute cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoglycemic, possible aspiration and intubated. Evaluate line\n position.\n\n COMPARISON: AP lateral views of the chest .\n\n AP UPRIGHT VIEW OF THE CHEST: Endotracheal tube is demonstrated with the tip\n 3.9 cm from the carina. Nasogastric tube tip projects in the fundus of the\n stomach. Cardiac silhouette is normal in size. Mediastinal and hilar\n contours are unchanged. Pulmonary vascularity is within normal limits. Hazy\n opacity within the left lower lung likely represents a small amount of pleural\n fluid. There is no pneumothorax.\n\n IMPRESSION: Satisfactory placement of endotracheal and nasogastric tubes.\n Small left pleural effusion.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2150-06-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969760, "text": " 2:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval changes\n Admitting Diagnosis: HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man found down brought to the OSH hypoglycemic, ? aspiration,\n extubated\n REASON FOR THIS EXAMINATION:\n please evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, :\n\n COMPARISON: .\n\n INDICATION: Hypoglycemia. Question aspiration.\n\n Right internal jugular vascular catheter terminates in the proximal superior\n vena cava. Cardiac contour and vascular pedicle width have slightly increased\n and are accompanied by worsening vascular engorgement, diffuse perihilar\n haziness and interstitial opacities, likely due to increased volume status and\n fluid overload. Superimposed secondary process such as aspiration is\n difficult to exclude in the setting of diffuse edema. Bilateral layering\n pleural effusions are noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969660, "text": " 4:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for changes\n Admitting Diagnosis: HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man found down brought to the OSH hypoglycemic, ? aspiration,\n intubated\n REASON FOR THIS EXAMINATION:\n eval for changes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Hypoglycemia, question aspiration.\n\n REFERENCE EXAM: .\n\n FINDINGS: There has been interval removal of the endotracheal tube and NG\n tube. The right IJ line tip is in the SVC. There are some hazy opacities in\n both lower lobes that could represent some early infiltrates as well as a\n subtle alveolar infiltrate in the right upper lobe. These could represent\n aspiration. Recommend followup.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-06-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 969533, "text": " 3:02 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Line placement.\n Admitting Diagnosis: HYPOGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man found down brought to the OSH hypoglycemic, ? aspiration,\n intubated\n REASON FOR THIS EXAMINATION:\n Line placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Found down, hypoglycemia, check line placement.\n\n FINDINGS: The endotracheal tube is in similar location compared to the film\n from the prior day. The NG tube is unchanged. There is a new right IJ line\n with tip in the SVC. There is some linear atelectasis in the left lower lung.\n No new infiltrates identified.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-06-20 00:00:00.000", "description": "Report", "row_id": 1599772, "text": "0700-1900\nneuro: lethargic, easily aroused, follows commands, oriented x 1\n\ncv: hr nsr, no ectopy, sbp stable(107-131)\n\nresp: extubated @ 1100, sat97-100 on 50% fm, pt doing well post extubation until iv fentanyl given x 2 for foreskin retraction by GU resident(25 mg iv x 2), pt noted to be snoring loudly, vbg sent, ph 7.20, pt placed on nasal BIPAP @ 1730, bs+ all lobes & clear, coughing & swollowing, minimal secretions\n\ngi: ogt dc'd with extubation, now npo due to somulance, no N/V or stool, po prevacid\n\ngu: foley patent, clear yellow urine, ua/c&s/lytes sent, ou 20-25 cc/hr, micu team aware, no tx\n\nother: wife in & updated on pt's condition, am MG 1.7 & repleated, d5lr@ 150cc/hr, insulin gtt started @ 0.5-1.0u/hr, gtt off for bs 38, 1 amp dextrose given, bs now 130, goal bs 150-120\n\nplan: continue to monitor resp status, wean off bipap as tolerated, insulin gtt as needed for bs > 200\n" }, { "category": "Nursing/other", "chartdate": "2150-06-21 00:00:00.000", "description": "Report", "row_id": 1599773, "text": "Resp Care\nPt received on nasal BiPAP. However becoming agitated and removing mask. Pt taken off Bipap at 8pm and placed on 2 L NC. Spo2=98%. VBG shows metabolic acidosis. See CareVue for details and specifics.\n\n" }, { "category": "Nursing/other", "chartdate": "2150-06-21 00:00:00.000", "description": "Report", "row_id": 1599774, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT AWAKE, CONFUSED AT TIMES. RESTLESS, MOVING CONSTANTLY IN BED. EALRY IN SHIFT PT CALLING OUT, MULTIPLE TIMES REORIENTED TO SURROUNDINGS. PT STILL WILL NOT USE CALL BELL. PT SLEPT ON AND OFF THOUGH OUT NIGHT.\n\nRESP: PT RECIEVED ON NASAL BIPAP. PT FOUND TO BE TAKING HIS MASK OFF, PULLING AT TUBING. BIPAP D/ SINCE PT MUCH MORE AWAKE. PLACED ON 2LNC. VBG DRAWN WITH PH 7.24. PT DID WELL WITH OUT BIPAP OVERNIGHT. O2 SATS 90'S.\n\nCV: HR 80-90'S NSR, SBP 120-140'S. AFEBRILE. AM LABS PENDING. IVF D5LR AT 150CC/HR.\n\nGI/GU: ABD SOFT, +BS, +BM. PT WILL CALL OUT FOR BEDPAN. PT NPO DUE TO LETHARGY AND POST EXTUBATION. WITH PT MORE AWAKE OVERNIGHT, POSSIBLE DIET TODAY. FOLEY INTACT DRAINING CLEAR YELLOW URINE.\n\nENDO: PT RECEIVED OFF INSULIN GTT. BS 168. AT MIDNIGHT BS 309. INSULIN GTT RESTARTED. MD, PT IS SENSITIVE TO INSULIN. THEY WOULD LIKE TO SEE HOW MUCH INSULIN HE REQUIRES IN A 24HR PERIOD. PER ORDERS INSULIN GTT STARTED AT .3U/HR AND TITRATED GENTLY. CURRENTLY AT 1U/HR WITH LAST BS 267.\n\nDISP: CLOSELY MONITOR BS THROUGH OUT DAY. START PT ON . MONITOR MS. CONTACT FROM PT'S WIFE OVERNIGHT. PT IS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2150-06-22 00:00:00.000", "description": "Report", "row_id": 1599777, "text": "Resp Care\nPt seen for Q6 neb treatments. BS coarse in upper aw's at times, however pt able to cough and clear secretions on command. Pt currently on 2 L NC, see carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2150-06-22 00:00:00.000", "description": "Report", "row_id": 1599778, "text": "Nursing Progress Note: 0700-1500\n\nPt. called out to floor and is being transferred to CC7.\n\nNo significant events during shift. Please see Nursing Transfer Note for review of systems and Carevue for objective data.\n\nPt. transferred in stable condition.\n\n" }, { "category": "Nursing/other", "chartdate": "2150-06-21 00:00:00.000", "description": "Report", "row_id": 1599775, "text": "NPN 07:00\nShift Events:\nOff Insulin gtt at 10am, bs q2hr, eating soft food (breakfast and lunch), and given Lantus 4u at ~13:00. BS currently 233 (patient lives in 200's), will check at 18:00 and cover with RISS. *Patient coughs/chokes on thin liquids (has had speech and swallows in past, recommended pureed food. Possible c/o to floor if bs remain wnl. **Written for Benadryl hs\n\nROS:\nNeuro: a/o x2-3, no c/o pain, mae's in bed, assists with turns.\nCV: HR 90's, NSR no ectopy, SBP 130-150's/70's.\nResp: LS clear, NC 2L o2 sat's high 90's-100%. Started on Nebs sleep apnea/copd.\nGI/GU: +bs, no bm. Started on IVF for decrease u/o, now wnl.\nAccess: TLC wnl\nEndo: Fixed dose and RISS.\nSocial: Wife in to visit this afternoon, updated on patients care.\n" }, { "category": "Nursing/other", "chartdate": "2150-06-22 00:00:00.000", "description": "Report", "row_id": 1599776, "text": "Nursing Progress Note:\nEVENTS: able to wean off insulin gtt during day yesterday; now on q2hr FS and coverage with RISS and standing lantus; pt to have speech/swallow in am d/t cough/choking on thin liqs and jello\n\nNEURO: A+O to person and place, at times appears confused with garbled speech, frequently calling out and making statements that don't make sense; denies pain; follows commands, right surgical pupil and left 3mm and brisk to react; moves all extremities but does not walk to to diabetic neuropathy\n\nCV: SBP 149-123; HR NSR/ST no ectopy 94-107; no CP; no edema noted; am labs pending\n\nRESP: pt with upper airway rattle, sometimes causes LS to sound rhonchorous, but are clear at apices and dim at bases; sats 96-99% on 2LNC, pt freequently pulling off NC, but does not desat on RA; +non-productive cough; as described above, pt given ginger ale on days and started to cough and choke, also happened in evening with jello; RR regular 15-20\n\nGI: + BSx4, + flatus; 2x loose brown stools tonight; abd soft non-tender non-distended; tolerating swabs until can be evaluated with speech/swallow\n\nGU: foley in place, draining adequate amt clear yellow urine\n\nACCESS: RIJ/TLC WNL\n\nENDO: continues on q2h FS, please see Careview; did recieve x1 dose 1unit insulin, otherwise covered on standing and RISS; pt with very labile BS\n\nSKIN: WNL\n\n: call out to floor in am; contiue to montior FS; speech/swallow consult\n" }, { "category": "Nursing/other", "chartdate": "2150-06-20 00:00:00.000", "description": "Report", "row_id": 1599769, "text": "Resp Care\nPt admitted from OSH. Pt intubated in field for AW protection with # 8 ETT. Witnessed vomiting/ aspiration prior to intubation. Pt currently on full vent support, FiO2 weaned this shift per SpO2. BS mostly clear bilaterally, some crackles heard bilaterally over upper AW's. Pt suctioned for small amounts of thick/ chunky tannish secretions. No ABG's this at this time. See CareVue for details and specifics.\nPlan: Wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2150-06-20 00:00:00.000", "description": "Report", "row_id": 1599770, "text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. HAS .\n\nPT. WAS FOUND DOWN BY WIFE AT 1300 . HE HAD BEEN LAST OBSERVED AT 1030 THAT MORNING. PT. WAS UNAROUSABLE AND HAD BLOOD SUGAR OF 6. UPON ARRIVAL, EMS INTUBATED PT. BUT PT. VOMITED AND ASPIRATED AT THAT TIME. PT. WAS TRANSFERRED FROM HOSPITAL FOR FURTHER WORK UP.\n\nPT. IS PRESENTLY LIGHTLY SEDATED WITH SMALL BOLUSES OF FENTANYL AND VERSED. GTT'S WHERE GOING TO BE HUNG BUT TEAM CHANGED THEIR MIND, IN HOPES THAT PT. WILL BE EXTUBATED THIS AM. PT. IS HYPOTHERMIC, BAIR HUGGER HAS BEEN ON SINCE 2330 LAST EVENING. AT PRESENT PT. IS JUST 95.7. WHEN PT. IS AWAKE HE IS NOTED TO MAE'S. HE HAS NOT BEEN NOTED TO FOLLOW ANY COMMANDS, NOR TRACK WITH HIS EYES.\n\nPT. IS NSB/SR 48-64 WITH NO NOTED ECTOPY. B/P REMAINS UNSUPPORTED AND HAS BEEN 120'S/80'S. PULSES ARE EXTREMELY DIFFICULT TO DOPPLER, BUT THEY ARE PRESENT. PT. HAS LONG HISTORY FOR VASCULAR ISSUES. HEART SOUNDS ARE DISTANT, BUT REGULAR.\n\nPT. REMAINS INTUBATED, REFER TO CAREVUE FOR LATEST SETTINGS. PT. HAS BEEN SUCTIONED FOR MODERATE AMT'S OF THICK/CHUNCKY TAN SECRETIONS. THIS HAS IMPROVED OVER THE SHIFT. LUNGS ARE ACTUALLY CLEARER NOW AND ARE NOTED CLEAR IN ALL FIELDS. O2 SATS READ 100%.\n\nPT'S BLOOD SUGARS HAS BEEN MUCH MORE CONTROLLED. PRESENTLY 125, WIFE STATES THAT HIS NORM IS >200, AND SHE IS AFRAID THAT THIS IS TOO LOW FOR HIM. ABD. IS BENIGN IN ASSESSMENT. BOWEL SOUND ARE EASILY AUDIBLE AND PT. HAS HAD TWO LARGE WHITE/TAN COLORED FOUL SMELLING STOOLS. THESE HAVE BOTH BEEN GUAIC NEGATIVE. PT. TAKES PANCREATIC ENZYMES AT HOME WITH ALL HIS . FOLEY CATHETER IS INTACT ADND DRAINING SCANT AMT'S OF CLEAR YELLOW URINE. PT. HAS BEEN WORKED UP OVER THE PAST TWO MONTHS FOR POSSIBLE DAILYSIS. HIS BASELINE CREATININE IS , AND AT PRESENT IS 4.5. URINARY OUTPUT HAS ONLY BEEN 10-15CC/HR.\n\nSKIN INTEGRITY EXHIBITS A FEW SCRAPS TO LOWER EXTREMITIES. WHICH ARE CLEANSED AND LEFT OTA. PT. ALSO HAS A EDEMATOUS FORESKIN, WHICH HAS BEEN EVALUATED BY MICU TEAM. PLANS ARE TO MONITOR AND MANUALLY PULL FORESKIN BACK OVER GLANDS. OTHERWISE PT. HAS TWO PIV'S ONE IN EACH AC. LEFT AC SITE IS SLIGHTLY REDDENED. PT. IS HAVING RIGHT SUBCLAVIAN LINE PLACED AND ONCE CONFIRMED, THIS WILL BE PULLED.\n\nPLAN IS TO EXTUBATE PT. MONITOR BLOOD SUGARS CLOSELY. GET CT HEAD REPORT FROM OSH, OTHERWISE PT. WILL NEED ANOTHER SCAN. PT. WILL ALSO BE EVALUATED FOR DAILYSIS.\n" }, { "category": "Nursing/other", "chartdate": "2150-06-20 00:00:00.000", "description": "Report", "row_id": 1599771, "text": "Resp Care\n\npt extubated without incident. Pt eventually began to retain Co2 by vbg. Attempting to use nasal bipap to lower co2.\n" }, { "category": "ECG", "chartdate": "2150-06-23 00:00:00.000", "description": "Report", "row_id": 127923, "text": "Sinus tachycardia. Left axis deviation with left anterior fascicular block.\nRight bundle-branch block. Possible old inferior wall myocardial infarction.\nLow QRS voltages in the precordial leads. Compared to tracing of there\nis no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2150-06-23 00:00:00.000", "description": "Report", "row_id": 127924, "text": "Sinus tachycardia. Right bundle-branch block. Left axis deviation. Left\nanterior fascicular block. Compared to previous tracing of heart\nrate is increased. Otherwise, multiple abnormalities as previously noted\npersist without major change.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2160-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 696469, "text": "HPI: Pt is a 71 yo F w/ significant PMH of COPD, DMII, HTN, CRI who\n was admitted to MICU from ED after visiting PCP today for cough,\n rhinorrhea, and dyspnea x 5 days. Pt was noted to have Sp02 in 80s on\n RA at PCP office who sent her to ED. Sp02 improved to 88-93 on 3L NC.\n She received atrovent and albuterol nebilizer in ED and zythromax for\n PNA prophylaxis though CXR is insignificant.\n Events:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received pt on 3 L NC w/ Sp02 87-92%. BLS Significant insp/exp wheeze\n and decreased breath sounds. Pt notefdto have Nasal congestion and\n congested cough. Denies any Discomfort and SOB,states that her\n breathing back to normal RR 16-20 .VSS.\n Action:\n Changed her neb rx frequency from q4h to Q2h,Switched her NC to Face\n tent . Given prednisone,Mucinex and MDI as ordered.\n Response:\n Bilat wheezing seems getting better, Pt upto chair denies any SOB.\n Tolerated her diet, SPO2 94-96% .\n Plan:\n Monitor resp status and hemodynamics. Obtain sputum sample, encourage\n CDB, follow blood cx data and CXRs.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with hx of DMII and also Prednisone. BG at 1200 373.\n Action:\n Received insulin according to RISS. Pt on diabetic diet.\n Response:\n --\n Plan:\n Cont SC insulin tx while pt is hospitalized.\n Impaired Health Maintenance\n Assessment:\n Pt states that she smokes approx\n PPD up until a few days before\n admission (she stopped d/t increased WOB / dyspnea at home). She also\n states that she stopped using her MDIs at home b/c they did not help.\n Action:\n Admin nebulizers and MDIs in hospital. Offer nicotine patch.\n Extensive teaching r/t the importance of smoking cessation and med\n compliance.\n Response:\n Pt observing her Sp02 improving and stating that she will follow her\n COPD med recommendations s/p discharge, however she refuses nicotine\n patch.\n Plan:\n Cont pt education.\n" }, { "category": "Nursing", "chartdate": "2160-10-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 696470, "text": "HPI: Pt is a 71 yo F w/ significant PMH of COPD, DMII, HTN, CRI who\n was admitted to MICU from ED after visiting PCP today for cough,\n rhinorrhea, and dyspnea x 5 days. Pt was noted to have Sp02 in 80s on\n RA at PCP office who sent her to ED. Sp02 improved to 88-93 on 3L NC.\n She received atrovent and albuterol nebilizer in ED and zythromax for\n PNA prophylaxis though CXR is insignificant.\n Events:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received pt on 3 L NC w/ Sp02 87-92%. BLS Significant insp/exp wheeze\n and decreased breath sounds. Pt notefdto have Nasal congestion and\n congested cough. Denies any Discomfort and SOB,states that her\n breathing back to normal RR 16-20 .VSS.\n Action:\n Changed her neb rx frequency from q4h to Q2h,Switched her NC to Face\n tent . Given prednisone,Mucinex and MDI as ordered.\n Response:\n Bilat wheezing seems getting better, Pt upto chair denies any SOB.\n Tolerated her diet, SPO2 94-96% . Pt c/o cold with face tent switched\n her back to 3L NC,tolerating fine Sating 92-94%.\n Plan:\n Monitor resp status and hemodynamics. Obtain sputum sample, encourage\n CDB, follow blood cx data and CXRs.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with hx of DMII and also Prednisone. BG at 1200 373.\n Action:\n Received insulin according to RISS. Pt on diabetic diet.\n Response:\n --\n Plan:\n Cont SC insulin tx while pt is hospitalized.\n Impaired Health Maintenance\n Assessment:\n Pt states that she smokes approx\n PPD up until a few days before\n admission (she stopped d/t increased WOB / dyspnea at home). She also\n states that she stopped using her MDIs at home b/c they did not help.\n Action:\n Admin nebulizers and MDIs in hospital. Offer nicotine patch.\n Extensive teaching r/t the importance of smoking cessation and med\n compliance.\n Response:\n Pt observing her Sp02 improving and stating that she will follow her\n COPD med recommendations s/p discharge, however she refuses nicotine\n patch.\n Plan:\n Cont pt education.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ASTHMA;COPD EXACERBATION\n Code status:\n Full code\n Height:\n 56 Inch\n Admission weight:\n 70.8 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: COPD, Diabetes - Oral , Smoker\n CV-PMH: Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:48\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 97 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Face tent\n O2 saturation:\n 94% %\n O2 flow:\n 35 L/min\n FiO2 set:\n 24h total in:\n 80 mL\n 24h total out:\n 450 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:42 AM\n Potassium:\n 5.0 mEq/L\n 04:42 AM\n Chloride:\n 102 mEq/L\n 04:42 AM\n CO2:\n 28 mEq/L\n 04:42 AM\n BUN:\n 32 mg/dL\n 04:42 AM\n Creatinine:\n 1.9 mg/dL\n 04:42 AM\n Glucose:\n 303 mg/dL\n 04:42 AM\n Hematocrit:\n 38.2 %\n 04:42 AM\n Finger Stick Glucose:\n 373\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 682\n Transferred to: 211\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2160-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 696295, "text": "HPI: Pt is a 71 yo F w/ significant PMH of COPD, DMII, HTN, CRI who\n was admitted to MICU from ED after visiting PCP today for cough,\n rhinorrhea, and dyspnea x 5 days. Pt was noted to have Sp02 in 80s on\n RA at PCP office who sent her to ED. Sp02 improved to 88-93 on 3L NC.\n She received atrovent and albuterol nebilizer in ED and zythromax for\n PNA prophylaxis though CXR is insignificant.\n Events:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received pt on 3 L NC w/ Sp02 87-92%. Significant insp/exp wheeze and\n decreased breath sounds at bases upon auscultation. Congested cough\n and notable nasal congestion. Mild use of accessory muscles w/\n breathing. Pt denies CP, dyspnea. RR 20-22. Pt is afebrile but c/o\n of feeling warm and noted to be diaphoretic when sleeping. Pt in NSR\n w/ rate 90-100.\n Action:\n Administer albuterol and atrovent nebs as ordered. Admin MDI,\n solumedrol, and mucinex as ordered.\n Response:\n Bilat wheezing decreasing, pt conts to deny subjective dyspnea. Pt\n remains afebrile, Sp02 89-98%.\n Plan:\n Monitor resp status and hemodynamics. Obtain sputum sample, encourage\n CDB, follow blood cx data and CXRs.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt has hx of DMII. BG at 0400 264.\n Action:\n Admin insulin according to RISS. Maintain diabetic diet.\n Response:\n Plan:\n Cont SC insulin tx while pt is hospitalized.\n Impaired Health Maintenance\n Assessment:\n Pt states that she smokes approx\n PPD up until a few days before\n admission (she stopped d/t increased WOB / dyspnea at home). She also\n states that she stopped using her MDIs at home b/c they did not help.\n Action:\n Admin nebulizers and MDIs in hospital. Offer nicotine patch.\n Extensive teaching r/t the importance of smoking cessation and med\n compliance.\n Response:\n Pt observing her Sp02 improving and stating that she will follow her\n med recommendations s/p discharge.\n Plan:\n Cont pt education.\n" }, { "category": "Physician ", "chartdate": "2160-10-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 696373, "text": "Chief Complaint: Respiratory Failure, COPD flare\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Doing well on 3L this AM\n 24 Hour Events:\n NASAL SWAB - At 02:00 AM\n BLOOD CULTURED - At 05:47 AM\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n per ICU team\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: Wheeze\n Genitourinary: No(t) Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35.6\nC (96.1\n HR: 103 (84 - 104) bpm\n BP: 116/38(58) {81/29(49) - 153/76(87)} mmHg\n RR: 21 (15 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 56 Inch\n Total In:\n 80 mL\n PO:\n 80 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n throughout)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 12.6 g/dL\n 250 K/uL\n 303 mg/dL\n 1.9 mg/dL\n 28 mEq/L\n 5.0 mEq/L\n 32 mg/dL\n 102 mEq/L\n 142 mEq/L\n 38.2 %\n 6.6 K/uL\n [image002.jpg]\n 04:42 AM\n WBC\n 6.6\n Hct\n 38.2\n Plt\n 250\n Cr\n 1.9\n Glucose\n 303\n Other labs: PT / PTT / INR:12.0/22.4/1.0, Differential-Neuts:90.4 %,\n Lymph:8.7 %, Mono:0.4 %, Eos:0.1 %, Ca++:9.6 mg/dL, Mg++:1.9 mg/dL,\n PO4:4.8 mg/dL\n Assessment and Plan\n 71 yo woman with COPD flare.\n COPD: -Cont pred 60mg --> slow taper\n -Azithromycin\n Renal Failure: Could be chronic --> will follow\n Remiander of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:01 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2160-10-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 696374, "text": "Chief Complaint: cough, hypoxia\n HPI:\n 71 F with a h/o COPD who has had multiple admissions for COPD in the\n past who presented to her PCP 5 days of nasal congestion,\n rhirrohea and cough. Her cough is productive of sputum, but she has\n not noted the color. Her SOB is slightly worse than baseline, but she\n has been able to do all of her ADLs. She denies chest pain or\n pressure. She reports a minor chronic daily cough at baseline. At her\n PCP's office she was noted to desat to the mid-80s and she was send to\n ED for further evaluation. She has been on home O2 in the past but not\n recently. She denies HA, sinus pressure, or sore throat. She denies\n sick contacts, recent long travel or swelling in her legs or PND. She\n does report that she cannot breathe as easily when laying flat.\n .\n In the ED, initial vs were: T 97.3 P 99 BP 160/84 R 18 O2 sat 92 on\n room air. Patient was given albuterol and ipratropium nebs, methylpred\n 125mg and azithromycin 500mg IV x1. Her CXR was negative for\n infiltrates or pulm edema. Her O2 sats decrease to 85% occasionally on\n 3.5L and then O2 sats increase without intervention.\n Her current VS are 93 153/63 18 95% on 3.5L.\n .\n On the floor, she is not in any respiratory distress and is able to\n speak in full sentences. She reports that she feels well currently.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDS:\n # Albuterol 90 mcg HFA 2 puffs(s) INH q4-6 hrs PRN - not taking\n # Fluticasone-Salmeterol 250 mcg-50 mcg 2 discs once daily - not taking\n # Furosemide 20 mg PO daily\n # Glipizide 15 mg PO q AM and 10mg PO qPM\n # Lisinopril 20 mg by mouth once a day\n # Metformin 1,000 mg Tablet by mouth twice a day\n # Nifedipine 30 mg by mouth once a day\n # Simvastatin 80 mg Tablet by mouth once a day\n # Aspirin 81 mg Tablet by mouth once a day\n Past medical history:\n Family history:\n Social History:\n # COPD - last PFTs FVC/FEV1 68, FVC 82% pred, FEV1 81% pred. stage\n I, mild COPD. She reports being on Home O2 for a period of months\n in the past. Her last COPD flare requiring steroids and admission was\n 1.5 years ago.\n # current tobacco use\n # DM II - hgb A1c 6.9\n # Obesity\n # Hyperlipidemia\n # Diverticulosis\n # h/o adrenal adenoma\n # herpes simplex\n # hx PE in setting of OCPs 30+ years ago\n # Chronic kidney diease - baseline Cr 1.5-2.0\n father died in 60's - EtOH\n mother died @ 36 - MI. obese, smoked\n sister - DM, renal failure\n brother - mentally retarded\n had 4 children, 1 son died @ 42 - EtOH, hemochromatosis, seizure\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She reports smoking 2PPD x 60 years. She has quit in the past\n for 6 months at a time and she has been smoking ppd recently. She\n denies EtOH or drugs. She lives alone and reports that she is able to\n complete all of her ADLs. She is able to walk for 15 min to and from\n the grocery store without getting SOB.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Pain: No pain / appears comfortable\n Flowsheet Data as of 01:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 97 (97 - 97) bpm\n BP: 153/61(81) {153/61(81) - 153/61(81)} mmHg\n RR: 22 (22 - 22) insp/min\n SpO2: 91%\n Height: 56 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -200 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n Physical Examination\n General: Alert & oriented x3, no acute distress, no accessory muscle\n use.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP @ 7cm, no LAD\n Lungs: poor airflow, + inspiratory and expiratory wheezes diffusely,\n no rales, ronchi. no dullness to percussion\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN 2-12 intact, MAE, sensation grossly intact\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs:\n 143 104 27\n ------------------< 120 AGap=15\n 4.7 29 1.8\n estGFR: 28/34 (click for details)\n MCV 89\n WBC 9.2\n HGB 12.8\n PLT 300\n HCT 38.7\n N:72.1 L:21.2 M:4.7 E:1.4 Bas:0.6\n Imaging: CXR - no acute cardiopulm process\n Microbiology: none\n ECG: NSR HR 99, PR & QRS wnl, rsR'in V1, no ST or TW changes.\n Assessment and Plan\n Assessment and Plan: This is a 71 yo f with history of mild COPD and\n current tobacco use who presents with a cough and hypoxia.\n # Hypoxia - Most likely secondary to a COPD exacerbation in setting of\n URI in a patient with current tob use and untreated COPD. She does not\n have evidence of volume overload on exam or on CXR. No e/o PNA on\n CXR. PE is less likely given lack of chest pain, predisposing risk\n factors or tachycardia.\n - supplemental O2 PRN, goal O2 sat>92%\n - albuterol & ipratropium nebs\n - advair inhaler.\n - pred 60mg PO daily\n - azithromycin 250 x4 days.\n - advise smoking cessation.\n - mucomyst 600mg PO BID\n - sputum cultures & blood cx.\n .\n # HTN - currently normotensive\n - continue home BP regimen with lisinopril and nifedipine\n .\n # DM, type II - anticipate worsening control with steroids\n - will monitor fs QID with ISS\n - hold metformin and glyburide for now.\n .\n # Chronic kidney disease - Creatinine 1.8. It appears as though her\n recent baseline was 1.5-2.0. Possibly some element of acute renal\n insufficiency. pt appears euvolemic. Will continue to monitor.\n - avoid nephrotoxins & will hold lasix given renal fun.\n .\n # Hyperlipidemia - continue statin.\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin, bowel reg, no PPI needed\n .\n # Access: peripherals\n .\n # Code: confirmed full with patient\n .\n # Communication: Patient & daughter \n ICU Care\n Nutrition: DM diet\n Glycemic Control: Regular insulin sliding scale, Comments: humalog ISS\n Lines:\n 20 Gauge - 12:01 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: likely to floor in am.\n ------ Protected Section ------\n Morning rounds\n Very comfortable on exam, reports no shortness of breath.\n -change nebs to Q2.\n -change from nasal cannula to shovel mask.\n -plan on possible transfer to floor this afternoon if oxygen sats\n remain stable.\n -send urine lytes and osms to check renal function.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:18 ------\n" }, { "category": "Physician ", "chartdate": "2160-10-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 696272, "text": "Chief Complaint: cough, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 71W with COPD - seen in PCP office today with c/o 5 days of URI\n symptoms, cough, minimal dyspnea. Sat in PCP office was low so referred\n to ER. In ER, afebrile, POx 92% on RA. CXR clear. Given antibiotics and\n steroids. Desating in ER when coughing.\n History obtained from housestaff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n COPD, previously on home O2\n active smoker\n DM2\n PE when on OCP's\n CRI\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Flowsheet Data as of 12:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 97 (97 - 97) bpm\n BP: 153/61(81) {153/61(81) - 153/61(81)} mmHg\n RR: 22 (22 - 22) insp/min\n SpO2: 91%\n Height: 56 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -200 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : , Wheezes : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Attentive, oriented\n Labs / Radiology\n 1.8\n [image002.jpg]\n ECG: NSR 99, no ischemia\n Assessment and Plan\n COPD flare, hypoxemia - likely triggered by viral URI - continue\n bronchodilators, steroids, azithro, wean O2 as tolerated\n DM - SSI\n HTN - continue antihypertensives\n ICU Care\n Nutrition: DM\n Glycemic Control:\n Lines:\n 20 Gauge - 12:01 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n" }, { "category": "Physician ", "chartdate": "2160-10-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 696277, "text": "Chief Complaint: cough, hypoxia\n HPI:\n 71 F with a h/o COPD who has had multiple admissions for COPD in the\n past who presented to her PCP 5 days of nasal congestion,\n rhirrohea and cough. Her cough is productive of sputum, but she has\n not noted the color. Her SOB is slightly worse than baseline, but she\n has been able to do all of her ADLs. She denies chest pain or\n pressure. She reports a minor chronic daily cough at baseline. At her\n PCP's office she was noted to desat to the mid-80s and she was send to\n ED for further evaluation. She has been on home O2 in the past but not\n recently. She denies HA, sinus pressure, or sore throat. She denies\n sick contacts, recent long travel or swelling in her legs or PND. She\n does report that she cannot breathe as easily when laying flat.\n .\n In the ED, initial vs were: T 97.3 P 99 BP 160/84 R 18 O2 sat 92 on\n room air. Patient was given albuterol and ipratropium nebs, methylpred\n 125mg and azithromycin 500mg IV x1. Her CXR was negative for\n infiltrates or pulm edema. Her O2 sats decrease to 85% occasionally on\n 3.5L and then O2 sats increase without intervention.\n Her current VS are 93 153/63 18 95% on 3.5L.\n .\n On the floor, she is not in any respiratory distress and is able to\n speak in full sentences. She reports that she feels well currently.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDS:\n # Albuterol 90 mcg HFA 2 puffs(s) INH q4-6 hrs PRN - not taking\n # Fluticasone-Salmeterol 250 mcg-50 mcg 2 discs once daily - not taking\n # Furosemide 20 mg PO daily\n # Glipizide 15 mg PO q AM and 10mg PO qPM\n # Lisinopril 20 mg by mouth once a day\n # Metformin 1,000 mg Tablet by mouth twice a day\n # Nifedipine 30 mg by mouth once a day\n # Simvastatin 80 mg Tablet by mouth once a day\n # Aspirin 81 mg Tablet by mouth once a day\n Past medical history:\n Family history:\n Social History:\n # COPD - last PFTs FVC/FEV1 68, FVC 82% pred, FEV1 81% pred. stage\n I, mild COPD. She reports being on Home O2 for a period of months\n in the past. Her last COPD flare requiring steroids and admission was\n 1.5 years ago.\n # current tobacco use\n # DM II - hgb A1c 6.9\n # Obesity\n # Hyperlipidemia\n # Diverticulosis\n # h/o adrenal adenoma\n # herpes simplex\n # hx PE in setting of OCPs 30+ years ago\n # Chronic kidney diease - baseline Cr 1.5-2.0\n father died in 60's - EtOH\n mother died @ 36 - MI. obese, smoked\n sister - DM, renal failure\n brother - mentally retarded\n had 4 children, 1 son died @ 42 - EtOH, hemochromatosis, seizure\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She reports smoking 2PPD x 60 years. She has quit in the past\n for 6 months at a time and she has been smoking ppd recently. She\n denies EtOH or drugs. She lives alone and reports that she is able to\n complete all of her ADLs. She is able to walk for 15 min to and from\n the grocery store without getting SOB.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Pain: No pain / appears comfortable\n Flowsheet Data as of 01:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 97 (97 - 97) bpm\n BP: 153/61(81) {153/61(81) - 153/61(81)} mmHg\n RR: 22 (22 - 22) insp/min\n SpO2: 91%\n Height: 56 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -200 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n Physical Examination\n General: Alert & oriented x3, no acute distress, no accessory muscle\n use.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP @ 7cm, no LAD\n Lungs: poor airflow, + inspiratory and expiratory wheezes diffusely,\n no rales, ronchi. no dullness to percussion\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: CN 2-12 intact, MAE, sensation grossly intact\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs:\n 143 104 27\n ------------------< 120 AGap=15\n 4.7 29 1.8\n estGFR: 28/34 (click for details)\n MCV 89\n WBC 9.2\n HGB 12.8\n PLT 300\n HCT 38.7\n N:72.1 L:21.2 M:4.7 E:1.4 Bas:0.6\n Imaging: CXR - no acute cardiopulm process\n Microbiology: none\n ECG: NSR HR 99, PR & QRS wnl, rsR'in V1, no ST or TW changes.\n Assessment and Plan\n Assessment and Plan: This is a 71 yo f with history of mild COPD and\n current tobacco use who presents with a cough and hypoxia.\n # Hypoxia - Most likely secondary to a COPD exacerbation in setting of\n URI in a patient with current tob use and untreated COPD. She does not\n have evidence of volume overload on exam or on CXR. No e/o PNA on\n CXR. PE is less likely given lack of chest pain, predisposing risk\n factors or tachycardia.\n - supplemental O2 PRN, goal O2 sat>92%\n - albuterol & ipratropium nebs\n - advair inhaler.\n - pred 60mg PO daily\n - azithromycin 250 x4 days.\n - advise smoking cessation.\n - mucomyst 600mg PO BID\n - sputum cultures & blood cx.\n .\n # HTN - currently normotensive\n - continue home BP regimen with lisinopril and nifedipine\n .\n # DM, type II - anticipate worsening control with steroids\n - will monitor fs QID with ISS\n - hold metformin and glyburide for now.\n .\n # Chronic kidney disease - Creatinine 1.8. It appears as though her\n recent baseline was 1.5-2.0. Possibly some element of acute renal\n insufficiency. pt appears euvolemic. Will continue to monitor.\n - avoid nephrotoxins & will hold lasix given renal fun.\n .\n # Hyperlipidemia - continue statin.\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin, bowel reg, no PPI needed\n .\n # Access: peripherals\n .\n # Code: confirmed full with patient\n .\n # Communication: Patient & daughter \n ICU Care\n Nutrition: DM diet\n Glycemic Control: Regular insulin sliding scale, Comments: humalog ISS\n Lines:\n 20 Gauge - 12:01 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: likely to floor in am.\n" }, { "category": "Nursing", "chartdate": "2160-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 696420, "text": "HPI: Pt is a 71 yo F w/ significant PMH of COPD, DMII, HTN, CRI who\n was admitted to MICU from ED after visiting PCP today for cough,\n rhinorrhea, and dyspnea x 5 days. Pt was noted to have Sp02 in 80s on\n RA at PCP office who sent her to ED. Sp02 improved to 88-93 on 3L NC.\n She received atrovent and albuterol nebilizer in ED and zythromax for\n PNA prophylaxis though CXR is insignificant.\n Events:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received pt on 3 L NC w/ Sp02 87-92%. BLS Significant insp/exp wheeze\n and decreased breath sounds. Pt notefdto have Nasal congestion and\n congested cough. Denies any Discomfort and SOB,states that her\n breathing back to normal RR 16-20 .VSS.\n Action:\n Changed her neb rx frequency from q4h to Q2h,Switched her NC to Face\n tent . Given prednisone,Mucinex and MDI as ordered.\n Response:\n Bilat wheezing seems getting better, Pt upto chair denies any SOB.\n Tolerated her diet,SPO2 94-96% .\n Plan:\n Monitor resp status and hemodynamics. Obtain sputum sample, encourage\n CDB, follow blood cx data and CXRs.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with hx of DMII and also Prednisone. BG at 0400 264.\n Action:\n Received insulin according to RISS. Pt on diabetic diet.\n Response:\n --\n Plan:\n Cont SC insulin tx while pt is hospitalized.\n Impaired Health Maintenance\n Assessment:\n Pt states that she smokes approx\n PPD up until a few days before\n admission (she stopped d/t increased WOB / dyspnea at home). She also\n states that she stopped using her MDIs at home b/c they did not help.\n Action:\n Admin nebulizers and MDIs in hospital. Offer nicotine patch.\n Extensive teaching r/t the importance of smoking cessation and med\n compliance.\n Response:\n Pt observing her Sp02 improving and stating that she will follow her\n COPD med recommendations s/p discharge, however she refuses nicotine\n patch.\n Plan:\n Cont pt education.\n" }, { "category": "Nursing", "chartdate": "2160-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 696350, "text": "HPI: Pt is a 71 yo F w/ significant PMH of COPD, DMII, HTN, CRI who\n was admitted to MICU from ED after visiting PCP today for cough,\n rhinorrhea, and dyspnea x 5 days. Pt was noted to have Sp02 in 80s on\n RA at PCP office who sent her to ED. Sp02 improved to 88-93 on 3L NC.\n She received atrovent and albuterol nebilizer in ED and zythromax for\n PNA prophylaxis though CXR is insignificant.\n Events:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received pt on 3 L NC w/ Sp02 87-92%. Significant insp/exp wheeze and\n decreased breath sounds at bases upon auscultation. Congested cough\n and notable nasal congestion. Mild use of accessory muscles w/\n breathing. Pt denies CP, dyspnea. RR 20-22. Pt is afebrile but c/o\n of feeling warm and noted to be diaphoretic when sleeping. Pt in NSR\n w/ rate 90-100.\n Action:\n Administer albuterol and atrovent nebs as ordered. Admin MDI,\n solumedrol, and mucinex as ordered.\n Response:\n Bilat wheezing decreasing, pt conts to deny subjective dyspnea. Pt\n remains afebrile, Sp02 89-98%.\n Plan:\n Monitor resp status and hemodynamics. Obtain sputum sample, encourage\n CDB, follow blood cx data and CXRs.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt has hx of DMII. BG at 0400 264.\n Action:\n Admin insulin according to RISS. Maintain diabetic diet.\n Response:\n --\n Plan:\n Cont SC insulin tx while pt is hospitalized.\n Impaired Health Maintenance\n Assessment:\n Pt states that she smokes approx\n PPD up until a few days before\n admission (she stopped d/t increased WOB / dyspnea at home). She also\n states that she stopped using her MDIs at home b/c they did not help.\n Action:\n Admin nebulizers and MDIs in hospital. Offer nicotine patch.\n Extensive teaching r/t the importance of smoking cessation and med\n compliance.\n Response:\n Pt observing her Sp02 improving and stating that she will follow her\n COPD med recommendations s/p discharge, however she refuses nicotine\n patch.\n Plan:\n Cont pt education.\n" }, { "category": "ECG", "chartdate": "2160-10-07 00:00:00.000", "description": "Report", "row_id": 117440, "text": "Sinus rhythm with atrial premature beat. RSR' pattern in lead V1. Compared to\nthe previous tracing of sinus tachycardia is absent and atrial\npremature beat is new.\n\n" }, { "category": "Radiology", "chartdate": "2160-10-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1097069, "text": " 4:36 PM\n CHEST (PA & LAT) Clip # \n Reason: COUGH,HYPOXIA HX COPD R/O CHF WET READ DR. ,IM \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with COPD\n REASON FOR THIS EXAMINATION:\n cough, hypoxia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh TUE 9:00 PM\n PFI: COPD with no acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old female with history of COPD, now with cough and hypoxia.\n\n STUDY: PA and lateral upright chest radiographs.\n\n COMPARISON STUDY: .\n\n FINDINGS: The cardiomediastinal silhouette appears unchanged. The hilum\n appears unremarkable bilaterally. There is flattening of the diaphragm and\n irregular distribution of pulmonary vessels consistent with COPD. No lobar\n consolidation is noted. No pleural abnormalities are seen. The osseous\n structures appear unremarkable.\n\n IMPRESSION: COPD with no acute cardiopulmonary process. The above findings\n were communicated to on .\n\n\n" }, { "category": "Radiology", "chartdate": "2160-10-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1097070, "text": ", B. -MCCN 4:36 PM\n CHEST (PA & LAT) Clip # \n Reason: COUGH,HYPOXIA HX COPD R/O CHF WET READ DR. ,IM \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with COPD\n REASON FOR THIS EXAMINATION:\n cough, hypoxia\n ______________________________________________________________________________\n PFI REPORT\n PFI: COPD with no acute cardiopulmonary process.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2159-11-17 00:00:00.000", "description": "Report", "row_id": 234985, "text": "Borderline sinus tachycardia. Rightward axis. Compared to the previous tracing\nof there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2159-11-16 00:00:00.000", "description": "Report", "row_id": 234986, "text": "Sinus rhythm. Right axis deviation. Non-specific ST-T wave changes. Compared\nto tracing of ST-T wave changes are new and sinus tachycardia is\nabsent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2159-11-15 00:00:00.000", "description": "Report", "row_id": 234987, "text": "Sinus tachycardia. Right axis deviation. No previous tracing available for\ncomparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2159-11-15 00:00:00.000", "description": "MR T-SPINE W &W/O CONTRAST", "row_id": 1100669, "text": " 9:10 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: eval for epidural abscess\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with neck pain, fever\n REASON FOR THIS EXAMINATION:\n eval for epidural abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc FRI 1:16 AM\n Study limited by motion. No extradural or intradural abnormality; no abnormal\n enhancement; no evidence of epidural abscess. Increased marrow signal in T1-\n T6, nonenhancing, likely fatty conversion rather than acute abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 38-year-old woman with neck pain and fever, evaluate for\n epidural abscess.\n\n TECHNIQUE: MRI of the cervical and thoracic spine were obtained both before\n and after the administration of intravenous contrast, as per the standard\n departmental protocol.\n\n COMPARISONS: None.\n\n FINDINGS: Image quality is markedly degraded by patient motion.\n\n MR CERVICAL SPINE: The vertebral body height and alignment is maintained.\n There is increased signal of the vertebral bodies in the lower cervical spine,\n which given the findings on the prior chest CT, likely reflects the sequela of\n radiation treatment.\n\n The visualized posterior fossa sign cord demonstrates gross normal\n configuration, accounting for patient motion. There is no definite evidence\n of abnormal enhancement.\n\n C2-3: Unremarkable.\n\n C3-4: There is a mild central disc protrusion indenting the ventral aspect of\n the thecal sac, but without significant spinal canal narrowing. The neural\n foramina are patent.\n\n C4-5: There are minimal uncovertebral osteophytes, resulting in mild neural\n foraminal narrowing bilaterally. There is flattening along the ventral aspect\n of the thecal sac, but without significant spinal canal narrowing.\n\n C5-6: There is endplate osteophyte and a mild disc bulge, which indents the\n ventral aspect of the thecal sac, but without significant compromise of the\n spinal cord. There are uncovertebral osteophytes as well, resulting in mild\n neural foraminal narrowing.\n\n C7-T1: Unremarkable.\n (Over)\n\n 9:10 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: eval for epidural abscess\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MR THORACIC SPINE: As on the cervical spine, image quality is degraded by\n patient motion. The vertebral body height and alignment is maintained. There\n is increased T1 signal intensity in the upper thoracic spine vertebral bodies,\n likely reflecting radiation changes.\n\n The visualized cord has a normal configuration. There are intrinsic areas of\n T1 hyperintensity along the ventral aspect of the cord, likely along the\n posterior margin of the spinal column, and likely representing epidural fat.\n There is no definite enhancement corresponding to these areas, although\n enhancement is difficult to assess given the intrinsic T1 hyperintensity on\n non-fat-suppressed images.\n\n The intervertebral disc height and signal is preserved. There is no evidence\n of significant spinal canal or neural foraminal narrowing at any of the\n visualized levels.\n\n There is a right pleural effusion and changes in the lung, better appreciated\n on the recent Ct.\n\n IMPRESSION:\n 1. Increased T1 hyperintensity of the vertebral bodies in the lower cervical\n and upper thoracic spine, likely reflecting post-radiation changes given the\n findings on the chest CT.\n\n 2. Mild degenerative changes in the cervical spine as detailed above, without\n evidence of significant spinal or neural foraminal narrowing in either the\n cervical or thoracic spine. However, the patient motion does decrease\n sensitivity for detection of subtle intradural or extradural abnormalities.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2159-11-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1100938, "text": " 6:54 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with ?PNA vs retrocardiac mass\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n WET READ: SHfd SAT 7:35 PM\n Worsening bilateral lung infiltrates. underlying mass not excluded.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: Retrocardiac mass. Possible pneumonia.\n\n IMPRESSION: AP chest compared to and 3:\n\n The frontal chest radiographs over the past 36 hours have suggested the\n development of a generalized interstitial pulmonary abnormality, but today's\n lateral view shows that the lower lobes are largely spared, and that the\n process has a great deal of coalescence in the right middle lobe. It also\n shows that the mass-like consolidation first seen on the chest CT, be shrinking. Overall findings suggest multifocal infection, partially\n treated, but perhaps due to more than one pathogen. The interstitial\n abnormality is very mild, could be a pulmonary drug reaction and is unlikely\n to be garden variety pulmonary edema in the absence of mediastinal vascular\n engorgement, progressive cardiac enlargement or pleural effusions. Findings\n were discussed over the telephone with the intern caring for this patient.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100857, "text": " 3:16 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with sepsis and resp failure\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:31 A.M., .\n\n HISTORY: Sepsis and respiratory failure.\n\n IMPRESSION: AP chest compared to :\n\n Diffuse infiltrative pulmonary abnormality has developed throughout the left\n lung and in the right mid lung since , following extubation. In the\n left mid lung projecting just lateral to the right hilus is a new 2-cm wide\n round opacity which could be a lung nodule, presumably infectious, or fissural\n fluid collection. The dramatic interval change could be due to massive\n aspiration, pulmonary hemorrhage or atypical edema. It would be very useful\n to know if the patient has had interim bronchoscopy for diagnosis of a\n mass-like consolidation at the medial left lung base which is less evident\n today, probably an artifact rather than real change. Heart size is normal.\n No pneumothorax or pleural effusion. Dr. and I discussed these\n findings.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-18 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1100977, "text": ", B. MED CC7A 9:14 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with PNA, appears worsening, now B/L by CXR\n REASON FOR THIS EXAMINATION:\n eval PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Evolution of new areas of mixed ground-glass and consolidative opacities\n bilaterally, which given their focality and the acuity of development are\n suggestive of bilateral infectious change.\n\n 2. Slight decrease in size of the anteromedial left lower lobe opacity, which\n given its change over three days is suggestive of an infectious consolidation\n as opposed to pulmonary mass. Nevertheless, followup to resolution is\n recommended.\n\n" }, { "category": "Physician ", "chartdate": "2159-11-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 488734, "text": "Chief Complaint: Hypotension\n Back/Neck Pain\n HPI:\n Ms is a 38 yo female with pmh of lung cancer, cervical cancer,\n and thyroid cancer (all unknown types) reproted to be in remission who\n presented to the morning of admission with\n neck and left lateral pain radiating toward the shoulder, with\n additional complaint of cough and fever. At the OSH she underwent a CT\n which new LLL consolidation vs. mass. She was given moxifloxacin, 2L\n IVF, and dilaudid and started becoming hypotensive. For concern for\n epidural abscess, she was transferred to the ED for further\n work-up and evaluation.\n ROS per documentation include very mild headacne (), cough, and\n chest pain that radiated to her shoulder as mentioned above.\n On arrival to the ED here her vitals were 74/42 HR 109 RR 18 and sat of\n 97% on 4L NC. She received 3.5L of crystalloid in our ED, plus 2L of\n crystalloid at the referring hospital.\n She had a central line placed in the right femoral artery and was\n started on levophed. Over the course of the day she had received 6 L\n IVF. Her antibiotics were broadened with vancomycin. She was also sent\n for a thoracic spine MRI, though developed an anaphylaxis reaction to\n receiving gadolinium, for which she received 0.3mg epinephrine, 125mg\n solumedrol, and was placed on non-rebreather for dropping o2 sats.\n Ultimately she was intubated with etomidate and succinylcholine.\n Gentamicin was ordered in the EW, but not received.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 150 mcg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 07:45 AM\n Other medications:\n Per OSH Paperwork: zoloft\n ritalin\n lamictal\n xanax\n trazadone\n albuterol prn\n combivent prn\n flonase\n neurontin\n Past medical history:\n Family history:\n Social History:\n Lung Cancer, Primary\n Cervical Cancer\n Thyroid Cancer\n Depression\n Irritable Bowel Syndrome\n Unknown\n Occupation: unknown\n Drugs:\n Tobacco: Current per records\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 07:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 71 (52 - 113) bpm\n BP: 108/58(80) {108/58(80) - 108/58(80)} mmHg\n RR: 22 (11 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 6,364 mL\n PO:\n TF:\n IVF:\n 3,364 mL\n Blood products:\n Total out:\n 0 mL\n 665 mL\n Urine:\n 665 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,699 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n SpO2: 98%\n ABG: 7.19/52/317/22/-8\n Ve: 7.1 L/min\n PaO2 / FiO2: 793\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: pupils constricted, reactive\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : basilar)\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 282 K/uL\n 10.8 g/dL\n 117 mg/dL\n 0.6 mg/dL\n 6 mg/dL\n 22 mEq/L\n 112 mEq/L\n 4.0 mEq/L\n 141 mEq/L\n 32.7 %\n 20.3 K/uL\n [image002.jpg]\n \n 2:33 A10/2/ 01:24 AM\n \n 10:20 P10/2/ 02:21 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.3\n Hct\n 32.7\n Plt\n 282\n Cr\n 0.6\n TC02\n 21\n Glucose\n 117\n Other labs: PT / PTT / INR:15.9/39.4/1.4, ALT / AST:, Alk Phos / T\n Bili:70/, Fibrinogen:624 mg/dL, Albumin:3.5 g/dL, Ca++:7.6 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Imaging: CT chest from OSH (): Preliminary Report !! WET READ !!\n LLL opacity appears low density most suggestive of partial collapse,\n concern for underlying mass. less likely pneumonia based on CT\n appearance. right effusion/pleural thickening, post-op changes, RUL\n opacity - could be consolidation vs chronic small pericardial effusion\n no PE or aortic dissection\n prelim read no epidural abscess.\n Abdominal CT: : normal abd/pelv CT. With IV and PO contrast,.\n Liver, gb, spleen, adrenals, aorta, panc, and kidneys normal. appendix\n is normal.\n Microbiology: UA - negative\n UCx - pending\n BCx x 2 - pending\n ECG: Sinus tachycardia at 100bpm, nl axis and intervals. nl r wave\n progression and no ischemic changes.\n Assessment and Plan\n 38 y/o F presents with fever, neck/chest/shoulder pain, and hypotension\n with findings suggestive of pulmonary infection vs new mass as source\n of sepsis.\n # Sepsis:\n Meets SIRS criteria given fever, leukocytosis, tachycardia, plus\n presumption of infection based on CT scan abnormality (though it is\n atypical). Potential sources based upon include\n - lungs (atypical, potentially post-obstructive, ?viral less likely)\n - lungs / legionella\n - meningitis\n - neck/soft tissue r/o Lemiere's\n - abdomen (though negative OSH CT scan with contrast)\n - urine (negative U/A)\n For diagnosis\n - consider CT head / neck soft tissues for further characterization\n given localization of complains and altered mental status once more\n hemodynamically stable\n - f/u final read of MRI C/T spine\n For therapy now,\n - fluid resusitation (consider changing CVL to neck line for CVP\n transduction, though neck veins do not appear elevated on exam)\n - norepinephrine infusion for MAP > 60\n - arterial line to transuce abp.\n For antibiotics\n - vancomycin 1000mg IV q12h\n - levofloxacin 750mg IV daily (in sub of moxifloxacin)\n - received one dose of gentamicin given allergy to beta lactams and\n prior allergic reaction this evening. If she continues to improve from\n , consider changing to aztreonam for trial.\n - defer anarobic coverage for now given no abscess present\n # Respiratory Failure: Intubated largely secondary to bronchospasm and\n anaphylaxis. Airway pressures now suggest no significant airway\n resistance now, implying that steroids and epinephrine have helped\n reduce the bronchospasm.\n - will remain intubated for now given critical illness\n - likely will be able to wean/extubate\n # LLL opacity: Prelim read of the OSH CT showed an opacity in the LLL\n concerning for collapse with a question of a mass. With her history of\n lung cancer, this could represent spread vs. new primary. Testing can\n be repeated as an outpatient to better differentiate between enlarging\n mass or improving consolidation\n .\n # Anemia: Hct of 35.8 on admission with an unknown baseline. No\n clinical evidence of bleeding. As she has received multiple liters of\n IVF, this could be dilutional.\n - Trend Hct\n .\n # Elevated coags: Patient's coags are slightly elevated. Her LFTs were\n WNL making acute liver disease unlikely. Given her sepsis she could be\n in DIC.\n - Will check DIC labs\n - Check albumin to assess nutritonal status\n .\n # Depression: She is on multple psych meds, though with unknown\n dosages. Will defer writing these now, and obtain further collateral\n information.\n # Anaphylaxis: to gadolinium; check of peak and plateau pressures are\n 20 and 17 respectively, suggesting that airway resistance has returned\n to normal from her earlier bronchospastic episode.\n - received steroids earlier\n - received epi sc earlier\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Presumed Full\n # CONTACT: Father: \n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:36 AM\n Multi Lumen - 02:37 AM\n 20 Gauge - 02:37 AM\n Arterial Line - 07:34 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2159-11-16 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 488738, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 38yo woman with a h/o depression, IBS, ? tobacco use, primary thyroid\n cancer, primary cervical cancer, and primary lung cancer who was\n referred from last night after having\n presented there with cough, fever, left-sided chest and lateral neck\n pain. There was some concern, at the OSH, for an epidural abscess.\n Evaluation at the OSH revealed a new LLL mass / opacity of unclear\n etiology. She did not have PE or aortic dissection. She was sent here\n for possible spine MRI.\n On arrival to our ER, she had a SBP of ~75mmHg. She received 3L IVF in\n our ER (after having received 2L at the OSH.) She received Moxiflox at\n the OSH, and received Vanc here (Gent was ordered but not given until\n she arrived to the MICU.) In the MRI she apparently developed wheezing\n and hypoxia after having received gad. She was treated for anaphylaxis\n and was eventually intubated for persistent hypoxia. She was started in\n the ED for hypotension with Levophed.\n On arrival to the MICU, her SBPs were transiently better and she came\n off Levophed; however, over the course of the morning it had to be\n restarted. An A-line was placed. She received a dose of Gent.\n 24 Hour Events:\n MULTI LUMEN - START 02:37 AM\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Levaquin\n Vancomycin\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 150 mcg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Heparin\n Colace\n Protonix\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 75 (52 - 113) bpm\n BP: 109/70 {89/50 - 120/91} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 6,341 mL\n PO:\n TF:\n IVF:\n 3,341 mL\n Blood products:\n Total out:\n 0 mL\n 665 mL\n Urine:\n 665 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,676 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n SpO2: 98%\n ABG: 7.19/52/317/22/-8\n Ve: 7.1 L/min\n PaO2 / FiO2: 793\n Physical Examination\n General: intubated, sedated.\n HEENT: Pin-point pupils. No LAD noted.\n CV: S1 S2 RRR with a III/VI SEM. No r/g\n Lungs: Scattered crackles without wheezing. Good air movement\n bilaterally.\n Ab: Positive BS\ns, NT/ND, no HSM noted.\n Ext: No c/c/e.\n Neuro: Sedated as above.\n Labs / Radiology\n 10.8 g/dL\n 282 K/uL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 112 mEq/L\n 141 mEq/L\n 32.7 %\n 20.3 K/uL\n [image002.jpg]\n Micro:\n Blood, urine, Legionella culture pending.\n Sputum not yet sent given she doesn\nt have significant secretions.\n 01:24 AM\n 02:21 AM\n WBC\n 20.3\n Hct\n 32.7\n Plt\n 282\n Cr\n 0.6\n TCO2\n 21\n Glucose\n 117\n Other labs:\n PT / PTT / INR:15.9/39.4/1.4,\n ALT / AST:, Alk Phos 70 / T Bili: /,\n Fibrinogen:624 mg/dL,\n Albumin:3.5 g/dL,\n Ca++:7.6 mg/dL, Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: 18 Gauge - 02:36 AM and Multi Lumen - \n 02:37 AM and 20 Gauge - 02:37 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2159-11-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 488741, "text": "Chief Complaint: Hypotension, Back/Neck Pain\n HPI:\n Ms is a 38 yo female with pmh of lung cancer, cervical cancer,\n and thyroid cancer (all unknown types) reproted to be in remission who\n presented to the morning of admission with\n neck and left lateral pain radiating toward the shoulder, with\n additional complaint of cough and fever. At the OSH she underwent a CT\n which new LLL consolidation vs. mass. She was given moxifloxacin, 2L\n IVF, and dilaudid and started becoming hypotensive. For concern for\n epidural abscess, she was transferred to the ED for further\n work-up and evaluation.\n ROS per documentation include very mild headacne (), cough, and\n chest pain that radiated to her shoulder as mentioned above.\n On arrival to the ED here her vitals were 74/42 HR 109 RR 18 and sat of\n 97% on 4L NC. She received 3.5L of crystalloid in our ED, plus 2L of\n crystalloid at the referring hospital.\n She had a central line placed in the right femoral artery and was\n started on levophed. Over the course of the day she had received 6 L\n IVF. Her antibiotics were broadened with vancomycin. She was also sent\n for a thoracic spine MRI, though developed an anaphylaxis reaction to\n receiving gadolinium, for which she received 0.3mg epinephrine, 125mg\n solumedrol, and was placed on non-rebreather for dropping o2 sats.\n Ultimately she was intubated with etomidate and succinylcholine.\n Gentamicin was ordered in the EW, but not received.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 150 mcg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 07:45 AM\n Other medications:\n Per OSH Paperwork: zoloft\n ritalin\n lamictal\n xanax\n trazadone\n albuterol prn\n combivent prn\n flonase\n neurontin\n Past medical history:\n Family history:\n Social History:\n Lung Cancer, Primary\n Cervical Cancer\n Thyroid Cancer\n Depression\n Irritable Bowel Syndrome\n Unknown\n Occupation: unknown\n Drugs:\n Tobacco: Current per records\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 07:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 71 (52 - 113) bpm\n BP: 108/58(80) {108/58(80) - 108/58(80)} mmHg\n RR: 22 (11 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 6,364 mL\n PO:\n TF:\n IVF:\n 3,364 mL\n Blood products:\n Total out:\n 0 mL\n 665 mL\n Urine:\n 665 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,699 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n SpO2: 98%\n ABG: 7.19/52/317/22/-8\n Ve: 7.1 L/min\n PaO2 / FiO2: 793\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: pupils constricted, reactive\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : basilar)\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 282 K/uL\n 10.8 g/dL\n 117 mg/dL\n 0.6 mg/dL\n 6 mg/dL\n 22 mEq/L\n 112 mEq/L\n 4.0 mEq/L\n 141 mEq/L\n 32.7 %\n 20.3 K/uL\n [image002.jpg]\n \n 2:33 A10/2/ 01:24 AM\n \n 10:20 P10/2/ 02:21 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.3\n Hct\n 32.7\n Plt\n 282\n Cr\n 0.6\n TC02\n 21\n Glucose\n 117\n Other labs: PT / PTT / INR:15.9/39.4/1.4, ALT / AST:, Alk Phos / T\n Bili:70/, Fibrinogen:624 mg/dL, Albumin:3.5 g/dL, Ca++:7.6 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Imaging: CT chest from OSH (): Preliminary Report !! WET READ !!\n LLL opacity appears low density most suggestive of partial collapse,\n concern for underlying mass. less likely pneumonia based on CT\n appearance. right effusion/pleural thickening, post-op changes, RUL\n opacity - could be consolidation vs chronic small pericardial effusion\n no PE or aortic dissection\n prelim read no epidural abscess.\n Abdominal CT: : normal abd/pelv CT. With IV and PO contrast,.\n Liver, gb, spleen, adrenals, aorta, panc, and kidneys normal. appendix\n is normal.\n Microbiology: UA - negative\n UCx - pending\n BCx x 2 - pending\n ECG: Sinus tachycardia at 100bpm, nl axis and intervals. nl r wave\n progression and no ischemic changes.\n Assessment and Plan\n 38 y/o F presents with fever, neck/chest/shoulder pain, and hypotension\n with findings suggestive of pulmonary infection vs new mass as source\n of sepsis.\n # Sepsis:\n Meets SIRS criteria given fever, leukocytosis, tachycardia, plus\n presumption of infection based on CT scan abnormality (though it is\n atypical). Potential sources based upon include:\n - lungs (atypical, potentially post-obstructive, ?viral less likely)\n - lungs / legionella\n - meningitis\n - neck/soft tissue r/o Lemiere's\n - abdomen (though negative OSH CT scan with contrast)\n - urine (negative U/A)\n For diagnosis\n - consider CT head / neck soft tissues for further characterization\n given localization of complains and altered mental status once more\n hemodynamically stable, but will hold if negative pulm workup\n - f/u final read of MRI C/T spine\n For therapy now,\n - fluid resusitation (consider changing CVL to neck line for CVP\n transduction, though neck veins do not appear elevated on exam)\n - norepinephrine infusion for MAP > 60\n - arterial line to transuce abp.\n - trend lactates, mixed venous O2 sat\n - will likely change to IJ for CVP\n For antibiotics\n - vancomycin 1000mg IV q12h\n - levofloxacin 750mg IV daily (in sub of moxifloxacin)\n - received one dose of gentamicin given allergy to beta lactams and\n prior allergic reaction this evening. If she continues to improve from\n anaphlyaxis, change to aztreonam today\n - defer anarobic coverage for now given no abscess present\n # Respiratory Failure: Intubated largely secondary to bronchospasm and\n anaphylaxis. Airway pressures now suggest no significant airway\n resistance now, implying that steroids and epinephrine have helped\n reduce the bronchospasm.\n - will remain intubated for now given critical illness\n - likely will be able to wean/extubate later today or tomorrow AM\n - bronchoscopy today\n # LLL opacity: Prelim read of the OSH CT showed an opacity in the LLL\n concerning for collapse with a question of a mass. With her history of\n lung cancer, this could represent spread vs. new primary. Testing can\n be repeated as an outpatient to better differentiate between enlarging\n mass or improving consolidation\n .\n # Anemia: Hct of 35.8 on admission with an unknown baseline. No\n clinical evidence of bleeding. As she has received multiple liters of\n IVF, this could be dilutional.\n - Trend Hct\n .\n # Elevated coags: Patient's coags are slightly elevated. Her LFTs were\n WNL making acute liver disease unlikely. Given her sepsis she could be\n in DIC - negative\n .\n # Depression: She is on multple psych meds, though with unknown\n dosages. Will defer writing these now, and obtain further collateral\n information.\n # Anaphylaxis: to gadolinium; check of peak and plateau pressures are\n 20 and 17 respectively, suggesting that airway resistance has returned\n to normal from her earlier bronchospastic episode.\n - received steroids earlier\n - received epi sc earlier\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Presumed Full\n # CONTACT: Father: \n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:36 AM\n Multi Lumen - 02:37 AM\n 20 Gauge - 02:37 AM\n Arterial Line - 07:34 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2159-11-16 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 488742, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 38yo woman with a h/o depression, IBS, ? tobacco use, primary thyroid\n cancer, primary cervical cancer, and primary lung cancer who was\n referred from last night after having\n presented there with cough, fever, left-sided chest and lateral neck\n pain. There was some concern, at the OSH, for an epidural abscess.\n Evaluation at the OSH revealed a new LLL mass / opacity of unclear\n etiology. She did not have PE or aortic dissection. She was sent here\n for possible spine MRI.\n On arrival to our ER, she had a SBP of ~75mmHg. She received 3L IVF in\n our ER (after having received 2L at the OSH.) She received Moxiflox at\n the OSH, and received Vanc here (Gent was ordered but not given until\n she arrived to the MICU.) In the MRI she apparently developed wheezing\n and hypoxia after having received gad. She was treated for anaphylaxis\n and was eventually intubated for persistent hypoxia. She was started in\n the ED for hypotension with Levophed.\n On arrival to the MICU, her SBPs were transiently better and she came\n off Levophed; however, over the course of the morning it had to be\n restarted. An A-line was placed. She received a dose of Gent.\n 24 Hour Events:\n MULTI LUMEN - START 02:37 AM\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Levaquin\n Vancomycin\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 150 mcg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Heparin\n Colace\n Protonix\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 75 (52 - 113) bpm\n BP: 109/70 {89/50 - 120/91} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 6,341 mL\n PO:\n TF:\n IVF:\n 3,341 mL\n Blood products:\n Total out:\n 0 mL\n 665 mL\n Urine:\n 665 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,676 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n SpO2: 98%\n ABG: 7.19/52/317/22/-8\n Ve: 7.1 L/min\n PaO2 / FiO2: 793\n Physical Examination\n General: intubated, sedated.\n HEENT: Pin-point pupils. No LAD noted.\n CV: S1 S2 RRR with a III/VI SEM. No r/g\n Lungs: Scattered crackles without wheezing. Good air movement\n bilaterally.\n Ab: Positive BS\ns, NT/ND, no HSM noted.\n Ext: No c/c/e.\n Neuro: Sedated as above.\n Labs / Radiology\n 10.8 g/dL\n 282 K/uL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 112 mEq/L\n 141 mEq/L\n 32.7 %\n 20.3 K/uL\n [image002.jpg]\n Micro:\n Blood, urine, Legionella culture pending.\n Sputum not yet sent given she doesn\nt have significant secretions.\n 01:24 AM\n 02:21 AM\n WBC\n 20.3\n Hct\n 32.7\n Plt\n 282\n Cr\n 0.6\n TCO2\n 21\n Glucose\n 117\n Other labs:\n PT / PTT / INR:15.9/39.4/1.4,\n ALT / AST:, Alk Phos 70 / T Bili: /,\n Fibrinogen:624 mg/dL,\n Albumin:3.5 g/dL,\n Ca++:7.6 mg/dL, Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 38yo woman with a h/o depression, IBS, ? tobacco use, primary thyroid\n cancer, primary cervical cancer, and primary lung cancer here with\n acute respiratory failure possibly an allergic reaction to\n gadolinium and hypotension possibly related to distributive shock.\n HYPOTENSION (NOT SHOCK)\n The cause of her hypotension is not entirely clear, but distributive\n shock is a possibility. The primary objective finding to date on her\n work-up is an apparently new consolidation in her LLL; her initial\n presentation is consistent with this as well\n left chest pain, fever,\n cough. Would pursue bronchoscopy for BAL, cytology and airway survery\n to further evaluate this consolidation. Agree with continuing Vanc,\n Gent and adding Aztreonam for second-line gram negative coverage.\n Given she remains intubated with a borderline blood pressure, it would\n be appropriate to change her CVL from the groin line to a neck or chest\n line. A-line is in place.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Anticipate that she should be extubated when she is otherwise stable\n from a hemodynamic and overall clinical perspective. Will provide\n bronchodilators given she is on that at home and to minimize\n bronchospasm.\n ELEVATED INR\n Would provide oral vitamin K; no evidence of DIC given stable platelets\n and fibrinogen.\n PSYCHIATRIC DISEASE\n Hold anti-psychotics for now, may restart Zoloft when her dose is\n clarified.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines: 18 Gauge - 02:36 AM and Multi Lumen - \n 02:37 AM and 20 Gauge - 02:37 AM\n Prophylaxis:\n DVT: Heparin subQ\n Stress ulcer: PPI\n VAP: VaP bundle ordereed.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU for now\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2159-11-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 489030, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with her\n note above, including and plan.\n HPI:\n 38yo woman with a h/o depression, IBS, tobacco use, reported primary\n thyroid cancer (this diagnosis is now quite doubtful after talking to\n the patient), primary cervical cancer (now likely simply an abnormal\n Pap smear and colpo), and primary lung cancer (s/p surgery / XRT /\n chemo) who was referred from on after\n having presented there with cough, fever, left-sided chest and lateral\n neck pain. Her work-up to date has been positive for only a LLL opacity\n on chest CT that appears to be consolidative, although a mass cannot be\n ruled out.\n 24 Hour Events:\n Pressors were weaned off yesterday morning.\n BRONCHOSCOPY - At 01:00 PM\n BAL in LLL performed,\n micro/cytology cxs sent\n INVASIVE VENTILATION - STOP 03:20 PM\n extubated\n successfully without complications.\n Remained somewhat somnolent after extubation, but improving\n overnight.\n Allergies:\n Penicillins\n Unknown;\n Gadolinium\n Anaphylaxis;\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM (one dose yesterday)\n Antibiotics Day 2:\n Levofloxacin - 08:26 AM\n Vancomycin - 08:19 PM\n Meropenem - 12:00 AM\n Infusions:\n Heparin subQ\n Colace\n Protonix 40mg q24h\n Nicotine patch\n Atrovent nebs\n Other ICU medications:\n Protonix - 12:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 101 (75 - 113) bpm\n BP: 126/70 {90/46 - 152/101} mmHg\n RR: 25 (16 - 30) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 7,302 mL\n 174 mL\n PO:\n TF:\n IVF:\n 4,302 mL\n 174 mL\n Blood products:\n Total out:\n 2,485 mL\n 630 mL\n Urine:\n 2,485 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,817 mL\n -456 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 641 (641 - 641) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 22\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.33/42/102/26/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n General: NAD, breathing comfortably.\n HEENT: Pin-point pupils. No LAD noted.\n CV: S1 S2 RRR with a III/VI SEM. No r/g\n Lungs: Scattered crackles without wheezing. Good air movement\n bilaterally.\n Ab: Positive BS\ns, NT/ND, no HSM noted.\n Ext: No c/c/e.\n Neuro: No focal deficits.\n Labs / Radiology\n 10.3 g/dL\n 271 K/uL\n 83 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.8 %\n 17.5 K/uL\n [image002.jpg]\n Micro:\n Bronchial washings ()\n gram stain 1+ PMNs, no organisms.\n Fem line catheter tip ()\n pending\n Blood cultures ()\n pending\n Chest x-ray:\n Markedly improved left basilar consolidation compared to yesterday,\n right upper lobe post-surgical changes.\n Spinal MRI:\n No narrowing or epidual abscesses.\n 01:24 AM\n 02:21 AM\n 12:25 PM\n 03:03 PM\n 05:03 PM\n 04:13 AM\n WBC\n 20.3\n 17.5\n Hct\n 32.7\n 33\n 30.8\n Plt\n 282\n 271\n Cr\n 0.6\n 0.6\n TCO2\n 21\n 22\n 21\n 23\n Glucose\n 117\n 83\n Other labs:\n PT / PTT / INR:15.9/39.4/1.4,\n ALT / AST:, Alk Phos / T Bili:70/,\n Fibrinogen:624 mg/dL,\n Lactic Acid:0.7 mmol/L, Albumin:3.5 g/dL,\n Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n and Plan\n 38yo woman with a h/o depression, IBS, tobacco use, primary thyroid\n cancer, primary cervical cancer, and primary lung cancer here with\n acute respiratory failure possibly an allergic reaction to\n gadolinium and transient hypotension possibly related to distributive\n shock that has resolved.\n HYPOTENSION (NOT SHOCK)\n Most likely her transient hypotension was due to distributive shock in\n the setting of a LLL pulmonary infection. Her bronch yesterday revealed\n some purulent secretions and micro samples from a BAL was sent for\n analysis. Her leukocytosis is imporving. Her She does have one of four\n blood culture bottles positive for GPCs which may be contaminant, but\n we will await speciation. Regardless, with supportive care and volume\n resuscitation, her BP has improved over the past 24 hours during which\n time she\ns been off pressors. Her A-line and the groin central line\n have been appropriately d/c\n PNEUMONIA\n As above, her presentation is consistent with a LLL pneumonia. Her\n culture data to date is unrevealing with the exception of the 1 out of\n 4 blood culture bottle demonstrating GPCs (suspect contaminant.) We\n will d/c Meropenem given no e/o a gram negative process. Would continue\n Levaquin and Vanc for today; if no e/o MRSA by tomorrow would\n transition her to monotherapy with Levaquin. She needs a f/u chest CT\n in ~4-8 weeks to ensure there is not a mass associated with or\n underlying her pneumonia, particularly given her h/o lung cancer.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n She was successfully extubated yesterday; the cause of her respiratory\n failure was likely a combination of anaphylaxis to gadolinium and her\n infectious / inflammatory process.\n WHEEZING / COPD\n She uses Combivent three times daily at home; she is quite wheezy on\n exam today. Would start Albuterol nebs standing q4h in addition to her\n Atrovent nebs. Would hold on steroids for the time being. She needs to\n completely quit smoking; continue nicotine patch. Provide incentive\n spirometry. Up out of bed.\n ELEVATED INR\n Follow INR. No e/o DIC.\n PSYCHIATRIC DISEASE\n Need to clarify her dose of anti-psychotics, would restart today. \n restart Zoloft when her dose is clarified.\n ICU Care\n Nutrition: ADAT\n Glycemic Control:\n Lines: 18 Gauge - 02:36 AM and 20 Gauge - 02:37 AM\n Prophylaxis:\n DVT: Heparin subQ\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Transfer to the floor today\n Total time spent:\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I would add the\n following. Wheezing on exam, moving air. Agree with holding steroids\n for now. Upon talking further with the patient there is no documented\n history of thyroid or cervical cancer (had an abnormal PAP and f/u\n colposcopy which did not reveal malignancy per the patient\ns report).\n I agree with Dr. \n and plan as detailed above.\n Time spent: 25 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 14:52 ------\n" }, { "category": "Respiratory ", "chartdate": "2159-11-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 488862, "text": "Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Scant\n Bedside Procedures:\n Bronchoscopy (13:00)\n Comments: Pt received intubated and vented on settings per resp.\n flowsheet. Bronched today for BAL . Pt did dip sats transiently post\n bronch to 88%. Sedation stopped and pt extubated. Currently on high\n flow neb at 96% with face tent, sats 94%. ABG post extubation\n 7.33/42/102/ -3\n" }, { "category": "Nursing", "chartdate": "2159-11-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 489014, "text": "Ms is a 38 yo female with pmh of lung cancer, cervical cancer,\n and thyroid cancer (all unknown types) reproted to be in remission who\n presented to the morning of admission with\n neck and left lateral pain radiating toward the shoulder, with\n additional complaint of cough and fever. At the OSH she underwent a CT\n which new LLL consolidation vs. mass. She was given moxifloxacin, 2L\n IVF, and dilaudid and started becoming hypotensive. For concern for\n epidural abscess, she was transferred to the ED for further\n work-up and evaluation.\n ROS per documentation include very mild headacne (), cough, and\n chest pain that radiated to her shoulder as mentioned above.\n On arrival to the ED here her vitals were 74/42 HR 109 RR 18 and sat of\n 97% on 4L NC. She received 3.5L of crystalloid in our ED, plus 2L of\n crystalloid at the referring hospital.\n She had a central line placed in the right femoral artery and was\n started on levophed. Over the course of the day she had received 6 L\n IVF. Her antibiotics were broadened with vancomycin. She was also sent\n for a thoracic spine MRI, though developed an anaphylaxis reaction to\n receiving gadolinium, for which she received 0.3mg epinephrine, 125mg\n solumedrol, and was placed on non-rebreather for dropping o2 sats.\n Ultimately she was intubated with etomidate and succinylcholine.\n Transferred to MICU for further management.\n MICU COURSE:\n Levophed gtt for hypotension.\n" }, { "category": "Nursing", "chartdate": "2159-11-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 489020, "text": "Ms is a 38 yo female with pmh of lung cancer, cervical cancer,\n and thyroid cancer (all unknown types) reproted to be in remission who\n presented to the morning of admission with\n neck and left lateral pain radiating toward the shoulder, with\n additional complaint of cough and fever. At the OSH she underwent a CT\n which new LLL consolidation vs. mass. She was given moxifloxacin, 2L\n IVF, and dilaudid and started becoming hypotensive. For concern for\n epidural abscess, she was transferred to the ED for further\n work-up and evaluation.\n ROS per documentation include very mild headacne (), cough, and\n chest pain that radiated to her shoulder as mentioned above.\n On arrival to the ED here her vitals were 74/42 HR 109 RR 18 and sat of\n 97% on 4L NC. She received 3.5L of crystalloid in our ED, plus 2L of\n crystalloid at the referring hospital.\n She had a central line placed in the right femoral artery and was\n started on levophed. Over the course of the day she had received 6 L\n IVF. Her antibiotics were broadened with vancomycin. She was also sent\n for a thoracic spine MRI, though developed an anaphylaxis reaction to\n receiving gadolinium, for which she received 0.3mg epinephrine, 125mg\n solumedrol, and was placed on non-rebreather for dropping o2 sats.\n Ultimately she was intubated with etomidate and succinylcholine.\n Transferred to MICU for further management.\n MICU COURSE:\n Levophed gtt for hypotension d/c\nd .\n Extubated without issue .\n Episode of nausea/emesis early in shift; received Zofran 4mg with\n desired effect.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 74 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Gadolinium-Containing Agents\n Anaphylaxis;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Ca lung,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:55\n Temperature:\n 98.4\n Arterial BP:\n S:135\n D:79\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 95% %\n 24h total in:\n 498 mL\n 24h total out:\n 2,160 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:13 AM\n Potassium:\n 3.8 mEq/L\n 04:13 AM\n Chloride:\n 106 mEq/L\n 04:13 AM\n CO2:\n 26 mEq/L\n 04:13 AM\n BUN:\n 8 mg/dL\n 04:13 AM\n Creatinine:\n 0.6 mg/dL\n 04:13 AM\n Glucose:\n 83 mg/dL\n 04:13 AM\n Hematocrit:\n 30.8 %\n 04:13 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7\n Transferred to: CC 709\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2159-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488694, "text": "38F h/o multiple primary cancers including lung cancer, thyroid and\n cervical (all unknown type) presented to OSH w/ c/o sharp CP radiating\n to Lt shoulder, cervical neck pain, fever, hypotension. CTA r/o PE,\n dissection showed LLL infiltrate vs. mass.\n" }, { "category": "Nursing", "chartdate": "2159-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488695, "text": "38F h/o multiple primary cancers including lung cancer, thyroid and\n cervical (all unknown type) presented to OSH w/ c/o sharp CP radiating\n to Lt shoulder, cervical neck pain, fever, hypotension. CTA r/o PE,\n showed LLL infiltrate vs. mass.\n Hypotension (not Shock)\n Assessment:\n Hypotensive to 80/45, also vasovagaled while attempting to do A line\n placement HR down from 80\ns to 50\n Action:\n Started on levophed GTT and titrated to 0.1mics/kg/min. Held A line\n placement temporarily.\n Response:\n Normotensive\n Plan:\n Titrate levophed for goal MAP >60\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was intubated in ED to protect airway. On vent AC/400/22/5/40%.\n Lung clear w/ mild crackles @ bases\n Action:\n Cont on sedation fentanyl GTT @ 150mics/kg/hr and versed GTT 5mg/hr\n Response:\n Pending\n Plan:\n Repeat ABG in AM. Follow MRI report.\n" }, { "category": "Nursing", "chartdate": "2159-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488836, "text": "Hypotension (not Shock)\n Assessment:\n Bp range 90\ns-110s. Maps >60.\n Action:\n Levophed dc\n Response:\n Maintained maps >60. Bp range ~100/50\ns at present.\n Plan:\n Cont to monitor hemodynamics. Maintain MAP>60.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished throughout. Rec\nd pt vented and sedated\n Action:\n Pt bronched at bedside. Bal and cytology/micro cxs sent. Pt weaned\n from sedation and extubated this afternoon to 100%face tent. Sats\n dropped to high 80\ns post extubation. Added NC as well to maintain sats\n >90. Pt encouraged to cough and deep breathe.\n Response:\n Post extubation ABG: 7.33/42/102. (lactate stable at 0.7).\n Plan:\n Encourage pt to cough and deep breathe. Follow up with bronch results.\n Wean from O2 as tolerated.\n Of note, pt had + blood cx ( from OSH), therefore right groin line\n dc\nd and tip sent for cx. Pt afebrile on IV vanco, levo and meropenum.\n Pt is presently lethargic, yet easily aroused. Oriented x2. Team has\n spoken to her father and he is aware of her admission to the hospital\n and present plan of care.\n" }, { "category": "Radiology", "chartdate": "2159-11-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100677, "text": " 12:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with SOb\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old female with shortness of breath. Evaluate for\n pneumonia.\n\n Single AP chest radiograph shows left basilar consolidation. Opacity along the\n medial right upper lobe correlates to a region of paramediastinal fibrosis on\n CT. There is right upper lobe post surgical change with accomanying pleural\n thickening. The heart size, hilar contours, and pulmonary vascularity are\n normal. There is no pleural effusion or pneumothorax.\n\n IMPRESSION:\n 1. Left basilar consolidation, which on CT appears mass like. Recommend\n comparison to prior exam.\n 2. Right upper lobe post-surgical change and paramediastinal fibrosis/pleural\n thickening.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-18 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1100976, "text": " 9:14 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with PNA, appears worsening, now B/L by CXR\n REASON FOR THIS EXAMINATION:\n eval PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc SUN 10:36 AM\n 1. Evolution of new areas of mixed ground-glass and consolidative opacities\n bilaterally, which given their focality and the acuity of development are\n suggestive of bilateral infectious change.\n\n 2. Slight decrease in size of the anteromedial left lower lobe opacity, which\n given its change over three days is suggestive of an infectious consolidation\n as opposed to pulmonary mass. Nevertheless, followup to resolution is\n recommended.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 38-year-old woman with pneumonia, now with clinical worsening.\n\n COMPARISON: Chest radiographs from as well as a CT\n of the chest from .\n\n TECHNIQUE: Axial CT images were acquired through the chest in the absence of\n intravenous contrast. Coronal and sagittal reformatted images were also\n reviewed.\n\n FINDINGS: Central airways are patent to subsegmental levels bilaterally. The\n left upper lobe reveals new areas of poorly marginated peribronchovascular\n opacities as well as ground-glass density, all of which is new from the study\n done a few days earlier. Similar, more scattered clusters of ground-glass\n density are visualized in the left lower lobe, also appearing new from the\n comparison study. Similar findings are present in the right lower lobe.\n Post-surgical changes are redemonstrated at the right upper lobe. The\n elevated right middle lobe contains new areas are more confluent opacities\n (3:26), corresponding to the findings described on the recent chest\n radiograph. An area of more mass-like confluence at the left lower lobe\n medially (4:15) is minimally changed. Small pleural effusions are visualized\n bilaterally including a nondependent settling of a right upper lobe pleural\n effusion, which is similar to that depicted on the comparison study. Also\n noted is small amount of pericardial fluid, slightly increased. Scattered\n nodes are visualized throughout the mediastinum and axilla, without\n enlargement by CT size criteria. Study is not tailored for evaluation of\n subdiaphragmatic contents, nevertheless those included appear unremarkable.\n\n Included osseous structures are unremarkable.\n\n IMPRESSION:\n 1. Evolution of new areas of mixed ground-glass and consolidative opacities\n (Over)\n\n 9:14 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bilaterally, which given their focality and the acuity of development are\n suggestive of bilateral infectious progression. Follow up to resolution is\n recommended.\n 2. Redemonstration and evolution of pleural effusions and tiny pericardial\n effusion.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-15 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1100661, "text": " 7:42 PM\n CT CHEST W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval for massj, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with ?LUL mass vs consolidation\n REASON FOR THIS EXAMINATION:\n eval for massj, pna\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:38 PM\n LLL opacity appears low density most suggestive of partial collapse, concern\n for underlying mass. less likely pneumonia based on CT appearance.\n right effusion/pleural thickening, post-op changes, RUL opacity - could be\n consolidation vs chronic\n small pericardial effusion\n no PE or aortic dissection\n\n comparison w/ prior studies would be helpful if available and information\n regarding medical/ history\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 38-year-old woman with question of left upper lobe mass or\n consolidation.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet through\n the lung bases after administration of 100 mL of Visipaque IV contrast.\n Reformatted images were not provided. This study was performed at\n and is submitted for a second opinion read. A\n formal report is not available. Verbal report indicates concern for a left\n upper lobe mass or consolidation.\n\n CHEST CT WITH IV CONTRAST: The thoracic aorta is normal in course and\n caliber, without dissection. There is no pulmonary embolism.\n\n Anterior medial opacity of the left lower lobe is nonenhancing and low density\n with irregular margins posteriorly. Findings area concerning for a pulmonary\n mass, although consolidation is possible. The left upper lobe is clear.\n There are post-surgical changes of the right lung. Bronchiectasis and linear\n opacities at the medial aspect of the right upper lobe consistent with\n paramedian fibrosis likely status post radiation changes. There is a suture\n line at the right lung apex. There is small amount of right upper pleural\n fluid. Right upper lobe pleural thickening is seen, which could be realted to\n post-radiation change, although comparison with priors is recommended. There\n is a focal right upper lobe opacity (2A:32) of uncertain chronicity. There is\n a small pericardial effusion/pleural thickeing. The heart is normal in size.\n A subcarinal lymph node measures 7 mm in short axis. There are no enlarged\n hilar or axillary lymph nodes.\n\n There are no bone lesions suspicious for malignancy. Imaging of the upper\n abdomen is unremarkable.\n (Over)\n\n 7:42 PM\n CT CHEST W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval for massj, pna\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. No pulmonary embolism. No aortic dissection.\n 2. Anteromedial left lower lobe opacity concerning for pulmonary mass,\n although consolidation is possible.\n 3. Post-surgical changes and likely post radiation treatment changes of the\n right upper lung. Right upper lobe pleural fluid and thickening. Please\n correlate with medical and surgical history and prior chest CTs.\n 4. Right upper lobe focal opacity that may represent post-treatment change vs\n infection. These findings are of uncertain chronicity and comparison with\n prior studies would be helpful.\n 5. Small pericardial effusion/thickening.\n\n" }, { "category": "Physician ", "chartdate": "2159-11-16 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 488723, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n MULTI LUMEN - START 02:37 AM\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 150 mcg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 75 (52 - 113) bpm\n BP: 109/70(79) {89/50(59) - 120/91(95)} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 6,341 mL\n PO:\n TF:\n IVF:\n 3,341 mL\n Blood products:\n Total out:\n 0 mL\n 665 mL\n Urine:\n 665 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,676 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n SpO2: 98%\n ABG: 7.19/52/317/22/-8\n Ve: 7.1 L/min\n PaO2 / FiO2: 793\n Physical Examination\n General:\n HEENT:\n CV:\n Lungs:\n Ab:\n Ext:\n Neuro:\n Labs / Radiology\n 10.8 g/dL\n 282 K/uL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 112 mEq/L\n 141 mEq/L\n 32.7 %\n 20.3 K/uL\n [image002.jpg]\n 01:24 AM\n 02:21 AM\n WBC\n 20.3\n Hct\n 32.7\n Plt\n 282\n Cr\n 0.6\n TCO2\n 21\n Glucose\n 117\n Other labs: PT / PTT / INR:15.9/39.4/1.4, ALT / AST:, Alk Phos / T\n Bili:70/, Fibrinogen:624 mg/dL, Albumin:3.5 g/dL, Ca++:7.6 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: 18 Gauge - 02:36 AM and Multi Lumen - \n 02:37 AM and 20 Gauge - 02:37 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2159-11-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 488731, "text": "Chief Complaint: Hypotension\n Back/Neck Pain\n HPI:\n Ms is a 38 yo female with pmh of lung cancer, cervical cancer,\n and thyroid cancer (all unknown types) reproted to be in remission who\n presented to the morning of admission with\n neck and left lateral pain radiating toward the shoulder, with\n additional complaint of cough and fever. At the OSH she underwent a CT\n which new LLL consolidation vs. mass. She was given moxifloxacin, 2L\n IVF, and dilaudid and started becoming hypotensive. For concern for\n epidural abscess, she was transferred to the ED for further\n work-up and evaluation.\n ROS per documentation include very mild headacne (), cough, and\n chest pain that radiated to her shoulder as mentioned above.\n On arrival to the ED here her vitals were 74/42 HR 109 RR 18 and sat of\n 97% on 4L NC. She received 3.5L of crystalloid in our ED, plus 2L of\n crystalloid at the referring hospital.\n She had a central line placed in the right femoral artery and was\n started on levophed. Over the course of the day she had received 6 L\n IVF. Her antibiotics were broadened with vancomycin. She was also sent\n for a thoracic spine MRI, though developed an anaphylaxis reaction to\n receiving gadolinium, for which she received 0.3mg epinephrine, 125mg\n solumedrol, and was placed on non-rebreather for dropping o2 sats.\n Ultimately she was intubated with etomidate and succinylcholine.\n Gentamicin was ordered in the EW, but not received.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 150 mcg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 07:45 AM\n Other medications:\n Per OSH Paperwork: zoloft\n ritalin\n lamictal\n xanax\n trazadone\n albuterol prn\n combivent prn\n flonase\n neurontin\n Past medical history:\n Family history:\n Social History:\n Lung Cancer, Primary\n Cervical Cancer\n Thyroid Cancer\n Depression\n Irritable Bowel Syndrome\n Unknown\n Occupation: unknown\n Drugs:\n Tobacco: Current per records\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 07:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 71 (52 - 113) bpm\n BP: 108/58(80) {108/58(80) - 108/58(80)} mmHg\n RR: 22 (11 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 6,364 mL\n PO:\n TF:\n IVF:\n 3,364 mL\n Blood products:\n Total out:\n 0 mL\n 665 mL\n Urine:\n 665 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,699 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n SpO2: 98%\n ABG: 7.19/52/317/22/-8\n Ve: 7.1 L/min\n PaO2 / FiO2: 793\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: pupils constricted, reactive\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : basilar)\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 282 K/uL\n 10.8 g/dL\n 117 mg/dL\n 0.6 mg/dL\n 6 mg/dL\n 22 mEq/L\n 112 mEq/L\n 4.0 mEq/L\n 141 mEq/L\n 32.7 %\n 20.3 K/uL\n [image002.jpg]\n \n 2:33 A10/2/ 01:24 AM\n \n 10:20 P10/2/ 02:21 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.3\n Hct\n 32.7\n Plt\n 282\n Cr\n 0.6\n TC02\n 21\n Glucose\n 117\n Other labs: PT / PTT / INR:15.9/39.4/1.4, ALT / AST:, Alk Phos / T\n Bili:70/, Fibrinogen:624 mg/dL, Albumin:3.5 g/dL, Ca++:7.6 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Imaging: CT chest from OSH (): Preliminary Report !! WET READ !!\n LLL opacity appears low density most suggestive of partial collapse,\n concern for underlying mass. less likely pneumonia based on CT\n appearance. right effusion/pleural thickening, post-op changes, RUL\n opacity - could be consolidation vs chronic small pericardial effusion\n no PE or aortic dissection\n prelim read no epidural abscess.\n Abdominal CT: : normal abd/pelv CT. With IV and PO contrast,.\n Liver, gb, spleen, adrenals, aorta, panc, and kidneys normal. appendix\n is normal.\n Microbiology: UA - negative\n UCx - pending\n BCx x 2 - pending\n ECG: Sinus tachycardia at 100bpm, nl axis and intervals. nl r wave\n progression and no ischemic changes.\n Assessment and Plan\n 38 y/o F presents with fever, neck/chest/shoulder pain, and hypotension\n with findings suggestive of pulmonary infection vs new mass as source\n of sepsis.\n # Sepsis:\n Meets SIRS criteria given fever, leukocytosis, tachycardia, plus\n presumption of infection based on CT scan abnormality (though it is\n atypical). Potential sources based upon include\n - lungs (atypical, potentially post-obstructive, ?viral less likely)\n - lungs / legionella\n - meningitis\n - neck/soft tissue r/o Lemiere's\n - abdomen (though negative OSH CT scan with contrast)\n - urine (negative U/A)\n For diagnosis\n - consider CT head / neck soft tissues for further characterization\n given localization of complains and altered mental status once more\n hemodynamically stable\n - f/u final read of MRI C/T spine\n For therapy now,\n - fluid resusitation (consider changing CVL to neck line for CVP\n transduction, though neck veins do not appear elevated on exam)\n - norepinephrine infusion for MAP > 60\n - arterial line to transuce abp.\n For antibiotics\n - vancomycin 1000mg IV q12h\n - levofloxacin 750mg IV daily (in sub of moxifloxacin)\n - received one dose of gentamicin given allergy to beta lactams and\n prior allergic reaction this evening. If she continues to improve from\n , consider changing to aztreonam for trial.\n - defer anarobic coverage for now given no abscess present\n # Respiratory Failure: Intubated largely secondary to bronchospasm and\n anaphylaxis. Airway pressures now suggest no significant airway\n resistance now, implying that steroids and epinephrine have helped\n reduce the bronchospasm.\n - will remain intubated for now given critical illness\n - likely will be able to wean/extubate\n # LLL opacity: Prelim read of the OSH CT showed an opacity in the LLL\n concerning for collapse with a question of a mass. With her history of\n lung cancer, this could represent spread vs. new primary. Testing can\n be repeated as an outpatient to better differentiate between enlarging\n mass or improving consolidation\n .\n # Anemia: Hct of 35.8 on admission with an unknown baseline. No\n clinical evidence of bleeding. As she has received multiple liters of\n IVF, this could be dilutional.\n - Trend Hct\n .\n # Elevated coags: Patient's coags are slightly elevated. Her LFTs were\n WNL making acute liver disease unlikely. Given her sepsis she could be\n in DIC.\n - Will check DIC labs\n - Check albumin to assess nutritonal status\n .\n # Depression: She is on multple psych meds, though with unknown\n dosages. Will defer writing these now, and obtain further collateral\n information.\n # Anaphylaxis: to gadolinium; check of peak and plateau pressures are\n 20 and 17 respectively, suggesting that airway resistance has returned\n to normal from her earlier bronchospastic episode.\n - received steroids earlier\n - received epi sc earlier\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Presumed Full\n # CONTACT: Father: \n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:36 AM\n Multi Lumen - 02:37 AM\n 20 Gauge - 02:37 AM\n Arterial Line - 07:34 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2159-11-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 489009, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2159-11-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 489012, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with her\n note above, including assessment and plan.\n HPI:\n 38yo woman with a h/o depression, IBS, tobacco use, reported primary\n thyroid cancer (this diagnosis is now quite doubtful after talking to\n the patient), primary cervical cancer (now likely simply an abnormal\n Pap smear and colpo), and primary lung cancer (s/p surgery / XRT /\n chemo) who was referred from on after\n having presented there with cough, fever, left-sided chest and lateral\n neck pain. Her work-up to date has been positive for only a LLL opacity\n on chest CT that appears to be consolidative, although a mass cannot be\n ruled out.\n 24 Hour Events:\n Pressors were weaned off yesterday morning.\n BRONCHOSCOPY - At 01:00 PM\n BAL in LLL performed,\n micro/cytology cxs sent\n INVASIVE VENTILATION - STOP 03:20 PM\n extubated\n successfully without complications.\n Remained somewhat somnolent after extubation, but improving\n overnight.\n Allergies:\n Penicillins\n Unknown;\n Gadolinium\n Anaphylaxis;\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM (one dose yesterday)\n Antibiotics Day 2:\n Levofloxacin - 08:26 AM\n Vancomycin - 08:19 PM\n Meropenem - 12:00 AM\n Infusions:\n Heparin subQ\n Colace\n Protonix 40mg q24h\n Nicotine patch\n Atrovent nebs\n Other ICU medications:\n Protonix - 12:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 101 (75 - 113) bpm\n BP: 126/70 {90/46 - 152/101} mmHg\n RR: 25 (16 - 30) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 7,302 mL\n 174 mL\n PO:\n TF:\n IVF:\n 4,302 mL\n 174 mL\n Blood products:\n Total out:\n 2,485 mL\n 630 mL\n Urine:\n 2,485 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,817 mL\n -456 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 641 (641 - 641) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 22\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.33/42/102/26/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n General: NAD, breathing comfortably.\n HEENT: Pin-point pupils. No LAD noted.\n CV: S1 S2 RRR with a III/VI SEM. No r/g\n Lungs: Scattered crackles without wheezing. Good air movement\n bilaterally.\n Ab: Positive BS\ns, NT/ND, no HSM noted.\n Ext: No c/c/e.\n Neuro: No focal deficits.\n Labs / Radiology\n 10.3 g/dL\n 271 K/uL\n 83 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.8 %\n 17.5 K/uL\n [image002.jpg]\n Micro:\n Bronchial washings ()\n gram stain 1+ PMNs, no organisms.\n Fem line catheter tip ()\n pending\n Blood cultures ()\n pending\n Chest x-ray:\n Markedly improved left basilar consolidation compared to yesterday,\n right upper lobe post-surgical changes.\n Spinal MRI:\n No narrowing or epidual abscesses.\n 01:24 AM\n 02:21 AM\n 12:25 PM\n 03:03 PM\n 05:03 PM\n 04:13 AM\n WBC\n 20.3\n 17.5\n Hct\n 32.7\n 33\n 30.8\n Plt\n 282\n 271\n Cr\n 0.6\n 0.6\n TCO2\n 21\n 22\n 21\n 23\n Glucose\n 117\n 83\n Other labs:\n PT / PTT / INR:15.9/39.4/1.4,\n ALT / AST:, Alk Phos / T Bili:70/,\n Fibrinogen:624 mg/dL,\n Lactic Acid:0.7 mmol/L, Albumin:3.5 g/dL,\n Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 38yo woman with a h/o depression, IBS, tobacco use, primary thyroid\n cancer, primary cervical cancer, and primary lung cancer here with\n acute respiratory failure possibly an allergic reaction to\n gadolinium and transient hypotension possibly related to distributive\n shock that has resolved.\n HYPOTENSION (NOT SHOCK)\n Most likely her transient hypotension was due to distributive shock in\n the setting of a LLL pulmonary infection. Her bronch yesterday revealed\n some purulent secretions and micro samples from a BAL was sent for\n analysis. Her leukocytosis is imporving. Her She does have one of four\n blood culture bottles positive for GPCs which may be contaminant, but\n we will await speciation. Regardless, with supportive care and volume\n resuscitation, her BP has improved over the past 24 hours during which\n time she\ns been off pressors. Her A-line and the groin central line\n have been appropriately d/c\n PNEUMONIA\n As above, her presentation is consistent with a LLL pneumonia. Her\n culture data to date is unrevealing with the exception of the 1 out of\n 4 blood culture bottle demonstrating GPCs (suspect contaminant.) We\n will d/c Meropenem given no e/o a gram negative process. Would continue\n Levaquin and Vanc for today; if no e/o MRSA by tomorrow would\n transition her to monotherapy with Levaquin. She needs a f/u chest CT\n in ~4-8 weeks to ensure there is not a mass associated with or\n underlying her pneumonia, particularly given her h/o lung cancer.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n She was successfully extubated yesterday; the cause of her respiratory\n failure was likely a combination of anaphylaxis to gadolinium and her\n infectious / inflammatory process.\n WHEEZING / COPD\n She uses Combivent three times daily at home; she is quite wheezy on\n exam today. Would start Albuterol nebs standing q4h in addition to her\n Atrovent nebs. Would hold on steroids for the time being. She needs to\n completely quit smoking; continue nicotine patch. Provide incentive\n spirometry. Up out of bed.\n ELEVATED INR\n Follow INR. No e/o DIC.\n PSYCHIATRIC DISEASE\n Need to clarify her dose of anti-psychotics, would restart today. \n restart Zoloft when her dose is clarified.\n ICU Care\n Nutrition: ADAT\n Glycemic Control:\n Lines: 18 Gauge - 02:36 AM and 20 Gauge - 02:37 AM\n Prophylaxis:\n DVT: Heparin subQ\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Transfer to the floor today\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2159-11-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 489013, "text": "Ms is a 38 yo female with pmh of lung cancer, cervical cancer,\n and thyroid cancer (all unknown types) reproted to be in remission who\n presented to the morning of admission with\n neck and left lateral pain radiating toward the shoulder, with\n additional complaint of cough and fever. At the OSH she underwent a CT\n which new LLL consolidation vs. mass. She was given moxifloxacin, 2L\n IVF, and dilaudid and started becoming hypotensive. For concern for\n epidural abscess, she was transferred to the ED for further\n work-up and evaluation.\n ROS per documentation include very mild headacne (), cough, and\n chest pain that radiated to her shoulder as mentioned above.\n On arrival to the ED here her vitals were 74/42 HR 109 RR 18 and sat of\n 97% on 4L NC. She received 3.5L of crystalloid in our ED, plus 2L of\n crystalloid at the referring hospital.\n She had a central line placed in the right femoral artery and was\n started on levophed. Over the course of the day she had received 6 L\n IVF. Her antibiotics were broadened with vancomycin. She was also sent\n for a thoracic spine MRI, though developed an anaphylaxis reaction to\n receiving gadolinium, for which she received 0.3mg epinephrine, 125mg\n solumedrol, and was placed on non-rebreather for dropping o2 sats.\n Ultimately she was intubated with etomidate and succinylcholine.\n Transferred to MICU for further management.\n MICU COURSE:\n Levophed gtt for hypotension.\n" }, { "category": "Physician ", "chartdate": "2159-11-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 488971, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BRONCHOSCOPY - At 01:00 PM\n BAL\n mucro/cytology cxs sent\n INVASIVE VENTILATION - STOP 03:20 PM\n Allergies:\n Penicillins\n Unknown;\n Gadolinium-Containing Agents\n Anaphylaxis;\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Levofloxacin - 08:26 AM\n Vancomycin - 08:19 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:05 PM\n Midazolam (Versed) - 01:05 PM\n Fentanyl - 01:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 101 (75 - 113) bpm\n BP: 126/70(91) {90/46(62) - 152/101(119)} mmHg\n RR: 25 (16 - 30) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 7,302 mL\n 174 mL\n PO:\n TF:\n IVF:\n 4,302 mL\n 174 mL\n Blood products:\n Total out:\n 2,485 mL\n 630 mL\n Urine:\n 2,485 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,817 mL\n -456 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 641 (641 - 641) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 22\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.33/42/102/26/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.3 g/dL\n 271 K/uL\n 83 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.8 %\n 17.5 K/uL\n [image002.jpg]\n 01:24 AM\n 02:21 AM\n 12:25 PM\n 03:03 PM\n 05:03 PM\n 04:13 AM\n WBC\n 20.3\n 17.5\n Hct\n 32.7\n 33\n 30.8\n Plt\n 282\n 271\n Cr\n 0.6\n 0.6\n TCO2\n 21\n 22\n 21\n 23\n Glucose\n 117\n 83\n Other labs: PT / PTT / INR:15.9/39.4/1.4, ALT / AST:, Alk Phos / T\n Bili:70/, Fibrinogen:624 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:3.5\n g/dL, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: 18 Gauge - 02:36 AM, 20 Gauge - 02:37 AM,\n and Arterial Line - 07:34 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2159-11-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 488975, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 38yo woman with a h/o depression, IBS, ? tobacco use, primary thyroid\n cancer, primary cervical cancer, and primary lung cancer who was\n referred from last night after having\n presented there with cough, fever, left-sided chest and lateral neck\n pain. Her work-up to date has been positive for only a LLL opacity on\n chest CT that appears to be consolidative, although a mass cannot be\n ruled out.\n 24 Hour Events:\n BRONCHOSCOPY - At 01:00 PM\n BAL in LLL performed,\n micro/cytology cxs sent\n INVASIVE VENTILATION - STOP 03:20 PM\n Allergies:\n Penicillins\n Unknown;\n Gadolinium\n Anaphylaxis;\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Levofloxacin - 08:26 AM\n Vancomycin - 08:19 PM\n Meropenem - 12:00 AM\n Infusions:\n Heparin\n Colace\n Protonix\n Other ICU medications:\n Protonix - 12:05 PM\n Versed - 01:05 PM\n Fentanyl - 01:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 101 (75 - 113) bpm\n BP: 126/70 {90/46 - 152/101} mmHg\n RR: 25 (16 - 30) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 7,302 mL\n 174 mL\n PO:\n TF:\n IVF:\n 4,302 mL\n 174 mL\n Blood products:\n Total out:\n 2,485 mL\n 630 mL\n Urine:\n 2,485 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,817 mL\n -456 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 641 (641 - 641) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 22\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.33/42/102/26/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n General: NAD, breathing comfortably.\n HEENT: Pin-point pupils. No LAD noted.\n CV: S1 S2 RRR with a III/VI SEM. No r/g\n Lungs: Scattered crackles without wheezing. Good air movement\n bilaterally.\n Ab: Positive BS\ns, NT/ND, no HSM noted.\n Ext: No c/c/e.\n Neuro: No focal deficits.\n Labs / Radiology\n 10.3 g/dL\n 271 K/uL\n 83 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.8 %\n 17.5 K/uL\n [image002.jpg]\n 01:24 AM\n 02:21 AM\n 12:25 PM\n 03:03 PM\n 05:03 PM\n 04:13 AM\n WBC\n 20.3\n 17.5\n Hct\n 32.7\n 33\n 30.8\n Plt\n 282\n 271\n Cr\n 0.6\n 0.6\n TCO2\n 21\n 22\n 21\n 23\n Glucose\n 117\n 83\n Other labs:\n PT / PTT / INR:15.9/39.4/1.4,\n ALT / AST:, Alk Phos / T Bili:70/,\n Fibrinogen:624 mg/dL,\n Lactic Acid:0.7 mmol/L, Albumin:3.5 g/dL,\n Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 38yo woman with a h/o depression, IBS, tobacco use, primary thyroid\n cancer, primary cervical cancer, and primary lung cancer here with\n acute respiratory failure possibly an allergic reaction to\n gadolinium and transient hypotension possibly related to distributive\n shock that has resolved.\n HYPOTENSION (NOT SHOCK)\n Most likely her transient hypotension was due to distributive shock in\n the setting of a LLL pulmonary infection. Her bronch yesterday revealed\n some purulent secretions and micro samples from a BAL was sent for\n analysis. In the interim, we will continue Vanc and Gent for broad\n coverage with a plan for de-escalation is cultures are not positive.\n She does have one of four blood culture bottles positive for GPCs which\n may be contaminant, but we will await speciation. Regardless, with\n supportive care and volume resuscitation, her BP has improved over the\n past 24 hours during which time she\ns been off pressors. Her A-line and\n the groin central line have been appropriately d/c\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n She was successfully extubated yesterday; the cause of her respiratory\n failure was likely a combination of anaphylaxis to gadolinium and her\n infectious / inflammatory process.\n ELEVATED INR\n Follow INR. No e/o DIC.\n PSYCHIATRIC DISEASE\n Hold anti-psychotics for now, may restart Zoloft when her dose is\n clarified.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines: 18 Gauge - 02:36 AM and Multi Lumen - \n 02:37 AM and 20 Gauge - 02:37 AM\n Prophylaxis:\n DVT: Heparin subQ\n Stress ulcer: PPI\n VAP: VaP bundle ordereed.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU for now\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2159-11-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 488958, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 01:00 PM\n BAL\n mucro/cytology cxs sent\n INVASIVE VENTILATION - STOP 03:20 PM\n - Admitted\n - Weaned off levophed at 9 AM\n - Updated father\n - ICU consent signed\n - Spoke to oncologist Dr. and oncology NP: treated lung\n cancer, did well, without evidence of recurrent disease, does not know\n about other cancers, has not seen oncologist in 1 year.\n - bronch with LLL with purulent secretions, BAL\n - post-bronch desat 89% --> FiO2 50% --> weaned to 40% --> PS\n - Blood culture from OSH - BCx with GPC, UCx NGTD\n - d/c femoral line and culture tip\n - extubated at 3 pm, but still somnolent\n Allergies:\n Penicillins\n Unknown;\n Gadolinium-Containing Agents\n Anaphylaxis;\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Levofloxacin - 08:26 AM\n Vancomycin - 08:19 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:05 PM\n Midazolam (Versed) - 01:05 PM\n Fentanyl - 01:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 96 (71 - 113) bpm\n BP: 112/63(81) {90/46(62) - 152/101(119)} mmHg\n RR: 23 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 7,302 mL\n 168 mL\n PO:\n TF:\n IVF:\n 4,302 mL\n 168 mL\n Blood products:\n Total out:\n 2,485 mL\n 510 mL\n Urine:\n 2,485 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,817 mL\n -342 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 641 (641 - 641) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 22\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 96%\n ABG: 7.33/42/102/26/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 271 K/uL\n 10.3 g/dL\n 83 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.8 %\n 17.5 K/uL\n [image002.jpg]\n 01:24 AM\n 02:21 AM\n 12:25 PM\n 03:03 PM\n 05:03 PM\n 04:13 AM\n WBC\n 20.3\n 17.5\n Hct\n 32.7\n 33\n 30.8\n Plt\n 282\n 271\n Cr\n 0.6\n 0.6\n TCO2\n 21\n 22\n 21\n 23\n Glucose\n 117\n 83\n Other labs: PT / PTT / INR:15.9/39.4/1.4, ALT / AST:, Alk Phos / T\n Bili:70/, Fibrinogen:624 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:3.5\n g/dL, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n CXR\n Single AP chest radiograph shows left basilar consolidation. Opacity\n along the\n medial right upper lobe correlates to a region of paramediastinal\n fibrosis on\n CT. There is right upper lobe post surgical change with accomanying\n pleural\n thickening. The heart size, hilar contours, and pulmonary vascularity\n are\n normal. There is no pleural effusion or pneumothorax.\n IMPRESSION:\n 1. Left basilar consolidation, which on CT appears mass like. Recommend\n comparison to prior exam.\n 2. Right upper lobe post-surgical change and paramediastinal\n fibrosis/pleural\n thickening.\n MR / T-SPINE\n IMPRESSION:\n 1. Increased T1 hyperintensity of the vertebral bodies in the lower\n cervical\n and upper thoracic spine, likely reflecting post-radiation changes\n given the\n findings on the chest CT.\n 2. Mild degenerative changes in the cervical spine as detailed above,\n without\n evidence of significant spinal or neural foraminal narrowing in either\n the\n cervical or thoracic spine. However, the patient motion does decrease\n sensitivity for detection of subtle intradural or extradural\n abnormalities.\n 1:24 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n LEGIONELLA CULTURE (Preliminary):\n POTASSIUM HYDROXIDE PREPARATION (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii)\n (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST SMEAR (Preliminary):\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n 1:24 pm Rapid Respiratory Viral Screen & Culture\n Respiratory Viral Culture (Pending):\n Respiratory Viral Antigen Screen (Pending):\n BCx: pending\n 2:52 pm CATHETER TIP-IV Source: femoral line.\n WOUND CULTURE (Pending):\n 3:11 am URINE Source: Catheter.\n Legionella Urinary Antigen (Final ):\n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.\n (Reference Range-Negative).\n BCx: pending\nOSH BCx GPCs\n Assessment and Plan\n ICU Care\n Nutrition: sips as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 02:36 AM\n 20 Gauge - 02:37 AM\n Arterial Line - 07:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2159-11-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 488959, "text": "24 Hour Events:\n BRONCHOSCOPY - At 01:00 PM\n BAL\n mucro/cytology cxs sent\n INVASIVE VENTILATION - STOP 03:20 PM\n - Admitted\n - Weaned off levophed at 9 AM\n - Updated father\n - ICU consent signed\n - Spoke to oncologist Dr. and oncology NP: treated lung\n cancer, did well, without evidence of recurrent disease, does not know\n about other cancers, has not seen oncologist in 1 year.\n - bronch with LLL with purulent secretions, BAL\n - post-bronch desat 89% --> FiO2 50% --> weaned to 40% --> PS\n - Blood culture from OSH - BCx with GPC, UCx NGTD\n - d/c femoral line and culture tip\n - extubated at 3 pm, but still somnolent\n Allergies:\n Penicillins\n Unknown;\n Gadolinium-Containing Agents\n Anaphylaxis;\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Levofloxacin - 08:26 AM\n Vancomycin - 08:19 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:05 PM\n Midazolam (Versed) - 01:05 PM\n Fentanyl - 01:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 96 (71 - 113) bpm\n BP: 112/63(81) {90/46(62) - 152/101(119)} mmHg\n RR: 23 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 7,302 mL\n 168 mL\n PO:\n TF:\n IVF:\n 4,302 mL\n 168 mL\n Blood products:\n Total out:\n 2,485 mL\n 510 mL\n Urine:\n 2,485 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,817 mL\n -342 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 641 (641 - 641) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 22\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 96%\n ABG: 7.33/42/102/26/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 271 K/uL\n 10.3 g/dL\n 83 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.8 %\n 17.5 K/uL\n [image002.jpg]\n 01:24 AM\n 02:21 AM\n 12:25 PM\n 03:03 PM\n 05:03 PM\n 04:13 AM\n WBC\n 20.3\n 17.5\n Hct\n 32.7\n 33\n 30.8\n Plt\n 282\n 271\n Cr\n 0.6\n 0.6\n TCO2\n 21\n 22\n 21\n 23\n Glucose\n 117\n 83\n Other labs: PT / PTT / INR:15.9/39.4/1.4, ALT / AST:, Alk Phos / T\n Bili:70/, Fibrinogen:624 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:3.5\n g/dL, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n CXR\n Single AP chest radiograph shows left basilar consolidation. Opacity\n along the\n medial right upper lobe correlates to a region of paramediastinal\n fibrosis on\n CT. There is right upper lobe post surgical change with accomanying\n pleural\n thickening. The heart size, hilar contours, and pulmonary vascularity\n are\n normal. There is no pleural effusion or pneumothorax.\n IMPRESSION:\n 1. Left basilar consolidation, which on CT appears mass like. Recommend\n comparison to prior exam.\n 2. Right upper lobe post-surgical change and paramediastinal\n fibrosis/pleural\n thickening.\n MR / T-SPINE\n IMPRESSION:\n 1. Increased T1 hyperintensity of the vertebral bodies in the lower\n cervical\n and upper thoracic spine, likely reflecting post-radiation changes\n given the\n findings on the chest CT.\n 2. Mild degenerative changes in the cervical spine as detailed above,\n without\n evidence of significant spinal or neural foraminal narrowing in either\n the\n cervical or thoracic spine. However, the patient motion does decrease\n sensitivity for detection of subtle intradural or extradural\n abnormalities.\n 1:24 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n LEGIONELLA CULTURE (Preliminary):\n POTASSIUM HYDROXIDE PREPARATION (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii)\n (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST SMEAR (Preliminary):\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n 1:24 pm Rapid Respiratory Viral Screen & Culture\n Respiratory Viral Culture (Pending):\n Respiratory Viral Antigen Screen (Pending):\n BCx: pending\n 2:52 pm CATHETER TIP-IV Source: femoral line.\n WOUND CULTURE (Pending):\n 3:11 am URINE Source: Catheter.\n Legionella Urinary Antigen (Final ):\n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.\n (Reference Range-Negative).\n BCx: pending\nOSH BCx GPCs\n Assessment and Plan 38 y/o F presents with fever, neck/chest/shoulder\n pain, and hypotension with findings suggestive of pulmonary infection\n vs new mass as source of sepsis.\n # Sepsis:\n Meets SIRS criteria given fever, leukocytosis, tachycardia, plus\n presumption of infection based on CT scan abnormality (though it is\n atypical). Potential sources based upon include:\n - lungs (atypical, potentially post-obstructive, ?viral less likely)\n - lungs / legionella\n - meningitis\n - neck/soft tissue r/o Lemiere's\n - abdomen (though negative OSH CT scan with contrast)\n - urine (negative U/A)\n For diagnosis\n - consider CT head / neck soft tissues for further characterization\n given localization of complains and altered mental status once more\n hemodynamically stable, but will hold if negative pulm workup\n - f/u final read of MRI C/T spine\n For therapy now,\n - fluid resusitation (consider changing CVL to neck line for CVP\n transduction, though neck veins do not appear elevated on exam)\n - norepinephrine infusion for MAP > 60\n - arterial line to transuce abp.\n - trend lactates, mixed venous O2 sat\n - will likely change to IJ for CVP\n For antibiotics\n - vancomycin 1000mg IV q12h\n - levofloxacin 750mg IV daily (in sub of moxifloxacin)\n - received one dose of gentamicin given allergy to beta lactams and\n prior allergic reaction this evening. If she continues to improve from\n anaphlyaxis, change to aztreonam today\n - defer anarobic coverage for now given no abscess present\n # Respiratory Failure: Intubated largely secondary to bronchospasm and\n anaphylaxis. Airway pressures now suggest no significant airway\n resistance now, implying that steroids and epinephrine have helped\n reduce the bronchospasm.\n - will remain intubated for now given critical illness\n - likely will be able to wean/extubate later today or tomorrow AM\n - bronchoscopy today\n # LLL opacity: Prelim read of the OSH CT showed an opacity in the LLL\n concerning for collapse with a question of a mass. With her history of\n lung cancer, this could represent spread vs. new primary. Testing can\n be repeated as an outpatient to better differentiate between enlarging\n mass or improving consolidation\n .\n # Anemia: Hct of 35.8 on admission with an unknown baseline. No\n clinical evidence of bleeding. As she has received multiple liters of\n IVF, this could be dilutional.\n - Trend Hct\n .\n # Elevated coags: Patient's coags are slightly elevated. Her LFTs were\n WNL making acute liver disease unlikely. Given her sepsis she could be\n in DIC - negative\n .\n # Depression: She is on multple psych meds, though with unknown\n dosages. Will defer writing these now, and obtain further collateral\n information.\n # Anaphylaxis: to gadolinium; check of peak and plateau pressures are\n 20 and 17 respectively, suggesting that airway resistance has returned\n to normal from her earlier bronchospastic episode.\n - received steroids earlier\n - received epi sc earlier\n ICU Care\n Nutrition: sips as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 02:36 AM\n 20 Gauge - 02:37 AM\n Arterial Line - 07:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2159-11-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 488960, "text": "24 Hour Events:\n BRONCHOSCOPY - At 01:00 PM\n BAL\n mucro/cytology cxs sent\n INVASIVE VENTILATION - STOP 03:20 PM\n - Admitted\n - Weaned off levophed at 9 AM\n - Updated father\n - ICU consent signed\n - Spoke to oncologist Dr. and oncology NP: treated lung\n cancer, did well, without evidence of recurrent disease, does not know\n about other cancers, has not seen oncologist in 1 year.\n - bronch with LLL with purulent secretions, BAL\n - post-bronch desat 89% --> FiO2 50% --> weaned to 40% --> PS\n - Blood culture from OSH - BCx with GPC, UCx NGTD\n - d/c femoral line and culture tip\n - extubated at 3 pm, but still somnolent\n Allergies:\n Penicillins\n Unknown;\n Gadolinium-Containing Agents\n Anaphylaxis;\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Levofloxacin - 08:26 AM\n Vancomycin - 08:19 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:05 PM\n Midazolam (Versed) - 01:05 PM\n Fentanyl - 01:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 96 (71 - 113) bpm\n BP: 112/63(81) {90/46(62) - 152/101(119)} mmHg\n RR: 23 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 7,302 mL\n 168 mL\n PO:\n TF:\n IVF:\n 4,302 mL\n 168 mL\n Blood products:\n Total out:\n 2,485 mL\n 510 mL\n Urine:\n 2,485 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,817 mL\n -342 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 641 (641 - 641) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 22\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 96%\n ABG: 7.33/42/102/26/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: pupils constricted, reactive\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : basilar)\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Somonolent\n Labs / Radiology\n 271 K/uL\n 10.3 g/dL\n 83 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.8 %\n 17.5 K/uL\n [image002.jpg]\n 01:24 AM\n 02:21 AM\n 12:25 PM\n 03:03 PM\n 05:03 PM\n 04:13 AM\n WBC\n 20.3\n 17.5\n Hct\n 32.7\n 33\n 30.8\n Plt\n 282\n 271\n Cr\n 0.6\n 0.6\n TCO2\n 21\n 22\n 21\n 23\n Glucose\n 117\n 83\n Other labs: PT / PTT / INR:15.9/39.4/1.4, ALT / AST:, Alk Phos / T\n Bili:70/, Fibrinogen:624 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:3.5\n g/dL, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n CXR\n Single AP chest radiograph shows left basilar consolidation. Opacity\n along the\n medial right upper lobe correlates to a region of paramediastinal\n fibrosis on\n CT. There is right upper lobe post surgical change with accomanying\n pleural\n thickening. The heart size, hilar contours, and pulmonary vascularity\n are\n normal. There is no pleural effusion or pneumothorax.\n IMPRESSION:\n 1. Left basilar consolidation, which on CT appears mass like. Recommend\n comparison to prior exam.\n 2. Right upper lobe post-surgical change and paramediastinal\n fibrosis/pleural\n thickening.\n MR / T-SPINE\n IMPRESSION:\n 1. Increased T1 hyperintensity of the vertebral bodies in the lower\n cervical\n and upper thoracic spine, likely reflecting post-radiation changes\n given the\n findings on the chest CT.\n 2. Mild degenerative changes in the cervical spine as detailed above,\n without\n evidence of significant spinal or neural foraminal narrowing in either\n the\n cervical or thoracic spine. However, the patient motion does decrease\n sensitivity for detection of subtle intradural or extradural\n abnormalities.\n 1:24 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n LEGIONELLA CULTURE (Preliminary):\n POTASSIUM HYDROXIDE PREPARATION (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii)\n (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST SMEAR (Preliminary):\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n 1:24 pm Rapid Respiratory Viral Screen & Culture\n Respiratory Viral Culture (Pending):\n Respiratory Viral Antigen Screen (Pending):\n BCx: pending\n 2:52 pm CATHETER TIP-IV Source: femoral line.\n WOUND CULTURE (Pending):\n 3:11 am URINE Source: Catheter.\n Legionella Urinary Antigen (Final ):\n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.\n (Reference Range-Negative).\n BCx: pending\nOSH BCx GPCs\n Assessment and Plan 38 y/o F presents with fever, neck/chest/shoulder\n pain, and hypotension with findings suggestive of pulmonary infection\n vs new mass as source of sepsis.\n # Sepsis:\n Meets SIRS criteria given fever, leukocytosis, tachycardia, plus\n presumption of infection based on CT scan abnormality (though it is\n atypical). Potential sources based upon include:\n - lungs (atypical, potentially post-obstructive, ?viral less likely)\n - lungs / legionella\n - meningitis\n - neck/soft tissue r/o Lemiere's\n - abdomen (though negative OSH CT scan with contrast)\n - urine (negative U/A)\n For diagnosis\n - consider CT head / neck soft tissues for further characterization\n given localization of complains and altered mental status once more\n hemodynamically stable, but will hold if negative pulm workup\n - f/u final read of MRI C/T spine\n For therapy now,\n - fluid resusitation (consider changing CVL to neck line for CVP\n transduction, though neck veins do not appear elevated on exam)\n - norepinephrine infusion for MAP > 60\n - arterial line to transuce abp.\n - trend lactates, mixed venous O2 sat\n - will likely change to IJ for CVP\n For antibiotics\n - vancomycin 1000mg IV q12h\n - levofloxacin 750mg IV daily (in sub of moxifloxacin)\n - received one dose of gentamicin given allergy to beta lactams and\n prior allergic reaction this evening. If she continues to improve from\n anaphlyaxis, change to aztreonam today\n - defer anarobic coverage for now given no abscess present\n # Respiratory Failure: Intubated largely secondary to bronchospasm and\n anaphylaxis. Airway pressures now suggest no significant airway\n resistance now, implying that steroids and epinephrine have helped\n reduce the bronchospasm.\n - will remain intubated for now given critical illness\n - likely will be able to wean/extubate later today or tomorrow AM\n - bronchoscopy today\n # LLL opacity: Prelim read of the OSH CT showed an opacity in the LLL\n concerning for collapse with a question of a mass. With her history of\n lung cancer, this could represent spread vs. new primary. Testing can\n be repeated as an outpatient to better differentiate between enlarging\n mass or improving consolidation\n .\n # Anemia: Hct of 35.8 on admission with an unknown baseline. No\n clinical evidence of bleeding. As she has received multiple liters of\n IVF, this could be dilutional.\n - Trend Hct\n .\n # Elevated coags: Patient's coags are slightly elevated. Her LFTs were\n WNL making acute liver disease unlikely. Given her sepsis she could be\n in DIC - negative\n .\n # Depression: She is on multple psych meds, though with unknown\n dosages. Will defer writing these now, and obtain further collateral\n information.\n # Anaphylaxis: to gadolinium; check of peak and plateau pressures are\n 20 and 17 respectively, suggesting that airway resistance has returned\n to normal from her earlier bronchospastic episode.\n - received steroids earlier\n - received epi sc earlier\n ICU Care\n Nutrition: sips as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 02:36 AM\n 20 Gauge - 02:37 AM\n Arterial Line - 07:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2159-11-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 488990, "text": "24 Hour Events:\n BRONCHOSCOPY - At 01:00 PM\n BAL\n mucro/cytology cxs sent\n INVASIVE VENTILATION - STOP 03:20 PM\n - Admitted\n - Weaned off levophed at 9 AM\n - Updated father\n - ICU consent signed\n - Spoke to oncologist Dr. and oncology NP: treated lung\n cancer, did well, without evidence of recurrent disease, does not know\n about other cancers, has not seen oncologist in 1 year.\n - bronch with LLL with purulent secretions, BAL\n - post-bronch desat 89% --> FiO2 50% --> weaned to 40% --> PS\n - Blood culture from OSH - BCx with GPC, UCx NGTD\n - d/c femoral line and culture tip\n - extubated at 3 pm, but still somnolent\n Allergies:\n Penicillins\n Unknown;\n Gadolinium-Containing Agents\n Anaphylaxis;\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Levofloxacin - 08:26 AM\n Vancomycin - 08:19 PM\n Meropenem - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:05 PM\n Midazolam (Versed) - 01:05 PM\n Fentanyl - 01:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 96 (71 - 113) bpm\n BP: 112/63(81) {90/46(62) - 152/101(119)} mmHg\n RR: 23 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 7,302 mL\n 168 mL\n PO:\n TF:\n IVF:\n 4,302 mL\n 168 mL\n Blood products:\n Total out:\n 2,485 mL\n 510 mL\n Urine:\n 2,485 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,817 mL\n -342 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 641 (641 - 641) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 22\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 96%\n ABG: 7.33/42/102/26/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: pupils constricted, reactive\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : basilar)\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Somonolent\n Labs / Radiology\n 271 K/uL\n 10.3 g/dL\n 83 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.8 %\n 17.5 K/uL\n [image002.jpg]\n 01:24 AM\n 02:21 AM\n 12:25 PM\n 03:03 PM\n 05:03 PM\n 04:13 AM\n WBC\n 20.3\n 17.5\n Hct\n 32.7\n 33\n 30.8\n Plt\n 282\n 271\n Cr\n 0.6\n 0.6\n TCO2\n 21\n 22\n 21\n 23\n Glucose\n 117\n 83\n Other labs: PT / PTT / INR:15.9/39.4/1.4, ALT / AST:, Alk Phos / T\n Bili:70/, Fibrinogen:624 mg/dL, Lactic Acid:0.7 mmol/L, Albumin:3.5\n g/dL, Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n CXR\n Single AP chest radiograph shows left basilar consolidation. Opacity\n along the\n medial right upper lobe correlates to a region of paramediastinal\n fibrosis on\n CT. There is right upper lobe post surgical change with accomanying\n pleural\n thickening. The heart size, hilar contours, and pulmonary vascularity\n are\n normal. There is no pleural effusion or pneumothorax.\n IMPRESSION:\n 1. Left basilar consolidation, which on CT appears mass like. Recommend\n comparison to prior exam.\n 2. Right upper lobe post-surgical change and paramediastinal\n fibrosis/pleural\n thickening.\n MR / T-SPINE\n IMPRESSION:\n 1. Increased T1 hyperintensity of the vertebral bodies in the lower\n cervical\n and upper thoracic spine, likely reflecting post-radiation changes\n given the\n findings on the chest CT.\n 2. Mild degenerative changes in the cervical spine as detailed above,\n without\n evidence of significant spinal or neural foraminal narrowing in either\n the\n cervical or thoracic spine. However, the patient motion does decrease\n sensitivity for detection of subtle intradural or extradural\n abnormalities.\n 1:24 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n LEGIONELLA CULTURE (Preliminary):\n POTASSIUM HYDROXIDE PREPARATION (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii)\n (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST SMEAR (Preliminary):\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n 1:24 pm Rapid Respiratory Viral Screen & Culture\n Respiratory Viral Culture (Pending):\n Respiratory Viral Antigen Screen (Pending):\n BCx: pending\n 2:52 pm CATHETER TIP-IV Source: femoral line.\n WOUND CULTURE (Pending):\n 3:11 am URINE Source: Catheter.\n Legionella Urinary Antigen (Final ):\n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.\n (Reference Range-Negative).\n BCx: pending\nOSH BCx GPCs\n Assessment and Plan 38 y/o F presents with fever, neck/chest/shoulder\n pain, and hypotension with findings suggestive of pulmonary infection\n vs new mass as source of sepsis.\n # Sepsis: Resolved. Fever improved, leukocytosis improved,\n tachycardia, plus presumption of infection based on CT scan abnormality\n (though it is atypical). Pressors off for 24 hours. Potential sources\n based upon include: lung most likely given findings on bronch with\n purulence removed from left lower lobe.\n - f/u sputum Cx and BAl\n - f/u BCx from OSH ? contaminant\n -cont Levo/Vanco, d/c meropenem\n -needs a follow up CT scan as outpatient\n - f/u final read of MRI C/T spine\n .\n # Respiratory Status: now extubuated and intubated largely secondary to\n bronchospasm and anaphylaxis. Sounds quite\n - f/u bronchoscopy cultures\n -start albuterol inhaler standing q4 hours\n ..\n # Anemia: Hct of 35.8 on admission with an unknown baseline. No\n clinical evidence of bleeding\n - Trend Hct\n .\n # Elevated coags: Patient's coags are slightly elevated. Her LFTs were\n WNL making acute liver disease unlikely. Not in DIC\n -daily INR\n .\n # Depression: She is on multple psych meds, though with unknown\n dosages. Will defer writing these now, and obtain further collateral\n information.\n -start home meds on floor\n # Anaphylaxis: to gadolinium; check of peak and plateau pressures are\n 20 and 17 respectively, suggesting that airway resistance has returned\n to normal from her earlier bronchospastic episode.\n - received steroids earlier\n - received epi sc earlier\n ICU Care\n Nutrition: advance to regular\n Glycemic Control:\n Lines:\n 18 Gauge - 02:36 AM\n 20 Gauge - 02:37 AM\n Arterial Line - 07:34 AM-will d/c today\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: call out to floor\n" }, { "category": "Physician ", "chartdate": "2159-11-17 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 488991, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with her\n note above, including assessment and plan.\n HPI:\n 38yo woman with a h/o depression, IBS, tobacco use, reported primary\n thyroid cancer (this diagnosis is now quite doubtful after talking to\n the patient), primary cervical cancer (now likely simply an abnormal\n Pap smear and colpo), and primary lung cancer (s/p surgery / XRT /\n chemo) who was referred from on after\n having presented there with cough, fever, left-sided chest and lateral\n neck pain. Her work-up to date has been positive for only a LLL opacity\n on chest CT that appears to be consolidative, although a mass cannot be\n ruled out.\n 24 Hour Events:\n Pressors were weaned off yesterday morning.\n BRONCHOSCOPY - At 01:00 PM\n BAL in LLL performed,\n micro/cytology cxs sent\n INVASIVE VENTILATION - STOP 03:20 PM\n extubated\n successfully without complications.\n Remained somewhat somnolent after extubation, but improving\n overnight.\n Allergies:\n Penicillins\n Unknown;\n Gadolinium\n Anaphylaxis;\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM (one dose yesterday)\n Antibiotics Day 2:\n Levofloxacin - 08:26 AM\n Vancomycin - 08:19 PM\n Meropenem - 12:00 AM\n Infusions:\n Heparin subQ\n Colace\n Protonix 40mg q24h\n Nicotine patch\n Atrovent nebs\n Other ICU medications:\n Protonix - 12:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.5\n HR: 101 (75 - 113) bpm\n BP: 126/70 {90/46 - 152/101} mmHg\n RR: 25 (16 - 30) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 7,302 mL\n 174 mL\n PO:\n TF:\n IVF:\n 4,302 mL\n 174 mL\n Blood products:\n Total out:\n 2,485 mL\n 630 mL\n Urine:\n 2,485 mL\n 630 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,817 mL\n -456 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 400) mL\n Vt (Spontaneous): 641 (641 - 641) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 12\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 22\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n Compliance: 36.4 cmH2O/mL\n SpO2: 99%\n ABG: 7.33/42/102/26/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 255\n Physical Examination\n General: NAD, breathing comfortably.\n HEENT: Pin-point pupils. No LAD noted.\n CV: S1 S2 RRR with a III/VI SEM. No r/g\n Lungs: Scattered crackles without wheezing. Good air movement\n bilaterally.\n Ab: Positive BS\ns, NT/ND, no HSM noted.\n Ext: No c/c/e.\n Neuro: No focal deficits.\n Labs / Radiology\n 10.3 g/dL\n 271 K/uL\n 83 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 106 mEq/L\n 138 mEq/L\n 30.8 %\n 17.5 K/uL\n [image002.jpg]\n Micro:\n Bronchial washings ()\n gram stain 1+ PMNs, no organisms.\n Fem line catheter tip ()\n pending\n Blood cultures ()\n pending\n Chest x-ray:\n Markedly improved left basilar consolidation compared to yesterday,\n right upper lobe post-surgical changes.\n Spinal MRI:\n No narrowing or epidual abscesses.\n 01:24 AM\n 02:21 AM\n 12:25 PM\n 03:03 PM\n 05:03 PM\n 04:13 AM\n WBC\n 20.3\n 17.5\n Hct\n 32.7\n 33\n 30.8\n Plt\n 282\n 271\n Cr\n 0.6\n 0.6\n TCO2\n 21\n 22\n 21\n 23\n Glucose\n 117\n 83\n Other labs:\n PT / PTT / INR:15.9/39.4/1.4,\n ALT / AST:, Alk Phos / T Bili:70/,\n Fibrinogen:624 mg/dL,\n Lactic Acid:0.7 mmol/L, Albumin:3.5 g/dL,\n Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 38yo woman with a h/o depression, IBS, tobacco use, primary thyroid\n cancer, primary cervical cancer, and primary lung cancer here with\n acute respiratory failure possibly an allergic reaction to\n gadolinium and transient hypotension possibly related to distributive\n shock that has resolved.\n HYPOTENSION (NOT SHOCK)\n Most likely her transient hypotension was due to distributive shock in\n the setting of a LLL pulmonary infection. Her bronch yesterday revealed\n some purulent secretions and micro samples from a BAL was sent for\n analysis. Her leukocytosis is imporving. Her She does have one of four\n blood culture bottles positive for GPCs which may be contaminant, but\n we will await speciation. Regardless, with supportive care and volume\n resuscitation, her BP has improved over the past 24 hours during which\n time she\ns been off pressors. Her A-line and the groin central line\n have been appropriately d/c\n PNEUMONIA\n As above, her presentation is consistent with a LLL pneumonia. Her\n culture data to date is unrevealing with the exception of the 1 out of\n 4 blood culture bottle demonstrating GPCs (suspect contaminant.) We\n will d/c Meropenem given no e/o a gram negative process. Would continue\n Levaquin and Vanc for today; if no e/o MRSA by tomorrow would\n transition her to monotherapy with Levaquin. She needs a f/u chest CT\n in ~4-8 weeks to ensure there is not a mass associated with or\n underlying her pneumonia, particularly given her h/o lung cancer.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n She was successfully extubated yesterday; the cause of her respiratory\n failure was likely a combination of anaphylaxis to gadolinium and her\n infectious / inflammatory process.\n WHEEZING / COPD\n She uses Combivent three times daily at home; she is quite wheezy on\n exam today. Would start Albuterol nebs standing q4h in addition to her\n Atrovent nebs. Would hold on steroids for the time being. She needs to\n completely quit smoking; continue nicotine patch. Provide incentive\n spirometry. Up out of bed.\n ELEVATED INR\n Follow INR. No e/o DIC.\n PSYCHIATRIC DISEASE\n Need to clarify her dose of anti-psychotics, would restart today. \n restart Zoloft when her dose is clarified.\n ICU Care\n Nutrition: ADAT\n Glycemic Control:\n Lines: 18 Gauge - 02:36 AM and 20 Gauge - 02:37 AM\n Prophylaxis:\n DVT: Heparin subQ\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Transfer to the floor today\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2159-11-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 488681, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Pt transferred from ED. On current vent settings, awaiting a-line\n placement.\n" }, { "category": "Physician ", "chartdate": "2159-11-16 00:00:00.000", "description": "Physician Fellow / Attending Progress Note - MICU", "row_id": 488787, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 38yo woman with a h/o depression, IBS, ? tobacco use, primary thyroid\n cancer, primary cervical cancer, and primary lung cancer who was\n referred from last night after having\n presented there with cough, fever, left-sided chest and lateral neck\n pain. There was some concern, at the OSH, for an epidural abscess.\n Evaluation at the OSH revealed a new LLL mass / opacity of unclear\n etiology. She did not have PE or aortic dissection. She was sent here\n for possible spine MRI.\n On arrival to our ER, she had a SBP of ~75mmHg. She received 3L IVF in\n our ER (after having received 2L at the OSH.) She received Moxiflox at\n the OSH, and received Vanc here (Gent was ordered but not given until\n she arrived to the MICU.) In the MRI she apparently developed wheezing\n and hypoxia after having received gad. She was treated for anaphylaxis\n and was eventually intubated for persistent hypoxia. She was started in\n the ED for hypotension with Levophed.\n On arrival to the MICU, her SBPs were transiently better and she came\n off Levophed; however, over the course of the morning it had to be\n restarted. An A-line was placed. She received a dose of Gent.\n 24 Hour Events:\n MULTI LUMEN - START 02:37 AM\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Levaquin\n Vancomycin\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 150 mcg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Heparin\n Colace\n Protonix\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 75 (52 - 113) bpm\n BP: 109/70 {89/50 - 120/91} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 6,341 mL\n PO:\n TF:\n IVF:\n 3,341 mL\n Blood products:\n Total out:\n 0 mL\n 665 mL\n Urine:\n 665 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,676 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n SpO2: 98%\n ABG: 7.19/52/317/22/-8\n Ve: 7.1 L/min\n PaO2 / FiO2: 793\n Physical Examination\n General: intubated, sedated.\n HEENT: Pin-point pupils. No LAD noted.\n CV: S1 S2 RRR with a III/VI SEM. No r/g\n Lungs: Scattered crackles without wheezing. Good air movement\n bilaterally.\n Ab: Positive BS\ns, NT/ND, no HSM noted.\n Ext: No c/c/e.\n Neuro: Sedated as above.\n Labs / Radiology\n 10.8 g/dL\n 282 K/uL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 6 mg/dL\n 112 mEq/L\n 141 mEq/L\n 32.7 %\n 20.3 K/uL\n [image002.jpg]\n Micro:\n Blood, urine, Legionella culture pending.\n Sputum not yet sent given she doesn\nt have significant secretions.\n 01:24 AM\n 02:21 AM\n WBC\n 20.3\n Hct\n 32.7\n Plt\n 282\n Cr\n 0.6\n TCO2\n 21\n Glucose\n 117\n Other labs:\n PT / PTT / INR:15.9/39.4/1.4,\n ALT / AST:, Alk Phos 70 / T Bili: /,\n Fibrinogen:624 mg/dL,\n Albumin:3.5 g/dL,\n Ca++:7.6 mg/dL, Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 38yo woman with a h/o depression, IBS, ? tobacco use, primary thyroid\n cancer, primary cervical cancer, and primary lung cancer here with\n acute respiratory failure possibly an allergic reaction to\n gadolinium and hypotension possibly related to distributive shock.\n HYPOTENSION (NOT SHOCK)\n The cause of her hypotension is not entirely clear, but distributive\n shock is a possibility. The primary objective finding to date on her\n work-up is an apparently new consolidation in her LLL; her initial\n presentation is consistent with this as well\n left chest pain, fever,\n cough. Would pursue bronchoscopy for BAL, cytology and airway survery\n to further evaluate this consolidation. Agree with continuing Vanc,\n Gent and adding Aztreonam for second-line gram negative coverage.\n Given she remains intubated with a borderline blood pressure, it would\n be appropriate to change her CVL from the groin line to a neck or chest\n line. A-line is in place.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Anticipate that she should be extubated when she is otherwise stable\n from a hemodynamic and overall clinical perspective. Will provide\n bronchodilators given she is on that at home and to minimize\n bronchospasm.\n ELEVATED INR\n Would provide oral vitamin K; no evidence of DIC given stable platelets\n and fibrinogen.\n PSYCHIATRIC DISEASE\n Hold anti-psychotics for now, may restart Zoloft when her dose is\n clarified.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines: 18 Gauge - 02:36 AM and Multi Lumen - \n 02:37 AM and 20 Gauge - 02:37 AM\n Prophylaxis:\n DVT: Heparin subQ\n Stress ulcer: PPI\n VAP: VaP bundle ordereed.\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU for now\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2159-11-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 488793, "text": "Chief Complaint: Hypotension, Back/Neck Pain\n HPI:\n Ms is a 38 yo female with pmh of lung cancer, cervical cancer,\n and thyroid cancer (all unknown types) reproted to be in remission who\n presented to the morning of admission with\n neck and left lateral pain radiating toward the shoulder, with\n additional complaint of cough and fever. At the OSH she underwent a CT\n which new LLL consolidation vs. mass. She was given moxifloxacin, 2L\n IVF, and dilaudid and started becoming hypotensive. For concern for\n epidural abscess, she was transferred to the ED for further\n work-up and evaluation.\n ROS per documentation include very mild headacne (), cough, and\n chest pain that radiated to her shoulder as mentioned above.\n On arrival to the ED here her vitals were 74/42 HR 109 RR 18 and sat of\n 97% on 4L NC. She received 3.5L of crystalloid in our ED, plus 2L of\n crystalloid at the referring hospital.\n She had a central line placed in the right femoral artery and was\n started on levophed. Over the course of the day she had received 6 L\n IVF. Her antibiotics were broadened with vancomycin. She was also sent\n for a thoracic spine MRI, though developed an anaphylaxis reaction to\n receiving gadolinium, for which she received 0.3mg epinephrine, 125mg\n solumedrol, and was placed on non-rebreather for dropping o2 sats.\n Ultimately she was intubated with etomidate and succinylcholine.\n Gentamicin was ordered in the EW, but not received.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Gentamicin - 04:17 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 150 mcg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 07:45 AM\n Other medications:\n Per OSH Paperwork: zoloft\n ritalin\n lamictal\n xanax\n trazadone\n albuterol prn\n combivent prn\n flonase\n neurontin\n Past medical history:\n Family history:\n Social History:\n Lung Cancer, Primary\n Cervical Cancer\n Thyroid Cancer\n Depression\n Irritable Bowel Syndrome\n Unknown\n Occupation: unknown\n Drugs:\n Tobacco: Current per records\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 07:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 71 (52 - 113) bpm\n BP: 108/58(80) {108/58(80) - 108/58(80)} mmHg\n RR: 22 (11 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 6,364 mL\n PO:\n TF:\n IVF:\n 3,364 mL\n Blood products:\n Total out:\n 0 mL\n 665 mL\n Urine:\n 665 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,699 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 21 cmH2O\n Plateau: 18 cmH2O\n SpO2: 98%\n ABG: 7.19/52/317/22/-8\n Ve: 7.1 L/min\n PaO2 / FiO2: 793\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: pupils constricted, reactive\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : basilar)\n Abdominal: Soft, Non-tender, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 282 K/uL\n 10.8 g/dL\n 117 mg/dL\n 0.6 mg/dL\n 6 mg/dL\n 22 mEq/L\n 112 mEq/L\n 4.0 mEq/L\n 141 mEq/L\n 32.7 %\n 20.3 K/uL\n [image002.jpg]\n \n 2:33 A10/2/ 01:24 AM\n \n 10:20 P10/2/ 02:21 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.3\n Hct\n 32.7\n Plt\n 282\n Cr\n 0.6\n TC02\n 21\n Glucose\n 117\n Other labs: PT / PTT / INR:15.9/39.4/1.4, ALT / AST:, Alk Phos / T\n Bili:70/, Fibrinogen:624 mg/dL, Albumin:3.5 g/dL, Ca++:7.6 mg/dL,\n Mg++:1.6 mg/dL, PO4:2.5 mg/dL\n Imaging: CT chest from OSH (): Preliminary Report !! WET READ !!\n LLL opacity appears low density most suggestive of partial collapse,\n concern for underlying mass. less likely pneumonia based on CT\n appearance. right effusion/pleural thickening, post-op changes, RUL\n opacity - could be consolidation vs chronic small pericardial effusion\n no PE or aortic dissection\n prelim read no epidural abscess.\n Abdominal CT: : normal abd/pelv CT. With IV and PO contrast,.\n Liver, gb, spleen, adrenals, aorta, panc, and kidneys normal. appendix\n is normal.\n Microbiology: UA - negative\n UCx - pending\n BCx x 2 - pending\n ECG: Sinus tachycardia at 100bpm, nl axis and intervals. nl r wave\n progression and no ischemic changes.\n Assessment and Plan\n 38 y/o F presents with fever, neck/chest/shoulder pain, and hypotension\n with findings suggestive of pulmonary infection vs new mass as source\n of sepsis.\n # Sepsis:\n Meets SIRS criteria given fever, leukocytosis, tachycardia, plus\n presumption of infection based on CT scan abnormality (though it is\n atypical). Potential sources based upon include:\n - lungs (atypical, potentially post-obstructive, ?viral less likely)\n - lungs / legionella\n - meningitis\n - neck/soft tissue r/o Lemiere's\n - abdomen (though negative OSH CT scan with contrast)\n - urine (negative U/A)\n For diagnosis\n - consider CT head / neck soft tissues for further characterization\n given localization of complains and altered mental status once more\n hemodynamically stable, but will hold if negative pulm workup\n - f/u final read of MRI C/T spine\n For therapy now,\n - fluid resusitation (consider changing CVL to neck line for CVP\n transduction, though neck veins do not appear elevated on exam)\n - norepinephrine infusion for MAP > 60\n - arterial line to transuce abp.\n - trend lactates, mixed venous O2 sat\n - will likely change to IJ for CVP\n For antibiotics\n - vancomycin 1000mg IV q12h\n - levofloxacin 750mg IV daily (in sub of moxifloxacin)\n - received one dose of gentamicin given allergy to beta lactams and\n prior allergic reaction this evening. If she continues to improve from\n anaphlyaxis, change to aztreonam today\n - defer anarobic coverage for now given no abscess present\n # Respiratory Failure: Intubated largely secondary to bronchospasm and\n anaphylaxis. Airway pressures now suggest no significant airway\n resistance now, implying that steroids and epinephrine have helped\n reduce the bronchospasm.\n - will remain intubated for now given critical illness\n - likely will be able to wean/extubate later today or tomorrow AM\n - bronchoscopy today\n # LLL opacity: Prelim read of the OSH CT showed an opacity in the LLL\n concerning for collapse with a question of a mass. With her history of\n lung cancer, this could represent spread vs. new primary. Testing can\n be repeated as an outpatient to better differentiate between enlarging\n mass or improving consolidation\n .\n # Anemia: Hct of 35.8 on admission with an unknown baseline. No\n clinical evidence of bleeding. As she has received multiple liters of\n IVF, this could be dilutional.\n - Trend Hct\n .\n # Elevated coags: Patient's coags are slightly elevated. Her LFTs were\n WNL making acute liver disease unlikely. Given her sepsis she could be\n in DIC - negative\n .\n # Depression: She is on multple psych meds, though with unknown\n dosages. Will defer writing these now, and obtain further collateral\n information.\n # Anaphylaxis: to gadolinium; check of peak and plateau pressures are\n 20 and 17 respectively, suggesting that airway resistance has returned\n to normal from her earlier bronchospastic episode.\n - received steroids earlier\n - received epi sc earlier\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Presumed Full\n # CONTACT: Father: \n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:36 AM\n Multi Lumen - 02:37 AM\n 20 Gauge - 02:37 AM\n Arterial Line - 07:34 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n CRITICAL CARE STAFF ADDENDUM\n I saw and examined Ms. with the ICU team and Dr. ,\n whose notes reflect my input. This 38-year-old woman with a history of\n multiple cancers (lung, cervical, and thyroid) came to MWH for neck and\n shoulder pain, cough, and fever. CT showed new LLL mass vs.\n consolidation. Hypotense. Sent to for further evaluation.\n Here, further hypotension (74/42). Taken for MRI to exclude epidural\n abscess but had anaphylactoid reaction to gadolinium. Treated, but\n eventually required intubation. CT showed:\n 1. No pulmonary embolism. No aortic dissection.\n 2. Anteromedial left lower lobe opacity concerning for pulmonary\n mass, although consolidation is possible.\n 3. Post-surgical changes and likely post radiation treatment\n changes of the right upper lung. Right upper lobe pleural fluid and\n thickening. Please correlate with medical and surgical history and\n prior chest CTs.\n 4. Right upper lobe focal opacity that may represent\n post-treatment change vs infection. These findings are of uncertain\n chronicity and comparison with prior studies would be helpful.\n 5. Small pericardial effusion/thickening.\n Here, on levophed but weaned off today.\n Assessment and Plan\n 38-year-old woman with multiple prior cancers now with fever,\n respiratory failure, and shock (now resolved). We will proceed to\n diagnostic bronchoscopy to exclude endobronchial lesions and get better\n micro samples. Will continue broad-spectrum antibiotics (vanc, levo,\n gent) for sepsis (shock now resolved). Consider swap to aztreonam.\n Potential extubation later today. Will need additional evaluation of\n lung mass unless bronchoscopy is diagnostic. Discussed with her father\n by our team. Other issues as per Dr. and Dr. .\n She is critically ill. 40 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:00 ------\n" }, { "category": "Nursing", "chartdate": "2159-11-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488924, "text": "38yo woman with a h/o depression, IBS, ? tobacco\n use, primary thyroid cancer, primary cervical cancer, and primary lung\n cancer who was referred from last night\n after having presented there with cough, fever, left-sided chest and\n lateral neck pain. There was some concern, at the OSH, for an epidural\n abscess. Evaluation at the OSH revealed a new LLL mass / opacity of\n unclear etiology. She did not have PE or aortic dissection. She was\n sent here for possible spine MRI.\n" }, { "category": "Nursing", "chartdate": "2159-11-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488926, "text": "38yo woman with a h/o depression, IBS, ? tobacco\n use, primary thyroid cancer, primary cervical cancer, and primary lung\n cancer who was referred from last night\n after having presented there with cough, fever, left-sided chest and\n lateral neck pain. There was some concern, at the OSH, for an epidural\n abscess. Evaluation at the OSH revealed a new LLL mass / opacity of\n unclear etiology. She did not have PE or aortic dissection. She was\n sent here for possible spine MRI. In the MRI she apparently developed\n wheezing and hypoxia after having received gad. She was treated for\n anaphylaxis and was eventually intubated for persistent hypoxia. She\n was started in the ED for hypotension with Levophed.\n" }, { "category": "Nutrition", "chartdate": "2159-11-16 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 488775, "text": "Subjective\n unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 74 kg\n 27.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 131%\n 61 kg\n Diagnosis: PNA\n PMHx: Lung Cancer, Primary\n Cervical Cancer\n Thyroid Cancer\n Depression\n Irritable Bowel Syndrome\n Food allergies and intolerances: mushrooms\n Pertinent medications: Fentanyl drip, Versed drip, normal saline @\n 10ml/hr, ABX, Pantoprazole, Colace, Magnesium sulfate (2g repletion)\n Labs:\n Value\n Date\n Glucose\n 117 mg/dL\n 02:21 AM\n BUN\n 6 mg/dL\n 02:21 AM\n Creatinine\n 0.6 mg/dL\n 02:21 AM\n Sodium\n 141 mEq/L\n 02:21 AM\n Potassium\n 4.0 mEq/L\n 02:21 AM\n Chloride\n 112 mEq/L\n 02:21 AM\n TCO2\n 22 mEq/L\n 02:21 AM\n PO2 (arterial)\n 89. mm Hg\n 12:25 PM\n PCO2 (arterial)\n 41 mm Hg\n 12:25 PM\n pH (arterial)\n 7.31 units\n 12:25 PM\n CO2 (Calc) arterial\n 22 mEq/L\n 12:25 PM\n Albumin\n 3.5 g/dL\n 02:21 AM\n Calcium non-ionized\n 7.6 mg/dL\n 02:21 AM\n Phosphorus\n 2.5 mg/dL\n 02:21 AM\n Magnesium\n 1.6 mg/dL\n 02:21 AM\n ALT\n 12 IU/L\n 02:21 AM\n Alkaline Phosphate\n 70 IU/L\n 02:21 AM\n AST\n 17 IU/L\n 02:21 AM\n WBC\n 20.3 K/uL\n 02:21 AM\n Hgb\n 10.8 g/dL\n 02:21 AM\n Hematocrit\n 32.7 %\n 02:21 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft, hypoactive bowel sounds, (+) flatus\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO, CA\n Estimated Nutritional Needs\n Calories: 1525-1830 (25-30 cal/kg)\n Protein: 73-85 (1.2-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: unknown\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n 38 YO female presented with sharp chest pain, fever, hypotension at\n outside hospital. CTA ruled out PE. CXR showed LLL infiltrate versus\n mass. Transferred to for spine \n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate:\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2159-11-16 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 488776, "text": "Subjective\n unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 74 kg\n 27.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 131%\n 61 kg\n Diagnosis: PNA\n PMHx: Lung Cancer, Primary\n Cervical Cancer\n Thyroid Cancer\n Depression\n Irritable Bowel Syndrome\n Food allergies and intolerances: mushrooms\n Pertinent medications: Fentanyl drip, Versed drip, normal saline @\n 10ml/hr, ABX, Pantoprazole, Colace, Magnesium sulfate (2g repletion)\n Labs:\n Value\n Date\n Glucose\n 117 mg/dL\n 02:21 AM\n BUN\n 6 mg/dL\n 02:21 AM\n Creatinine\n 0.6 mg/dL\n 02:21 AM\n Sodium\n 141 mEq/L\n 02:21 AM\n Potassium\n 4.0 mEq/L\n 02:21 AM\n Chloride\n 112 mEq/L\n 02:21 AM\n TCO2\n 22 mEq/L\n 02:21 AM\n PO2 (arterial)\n 89. mm Hg\n 12:25 PM\n PCO2 (arterial)\n 41 mm Hg\n 12:25 PM\n pH (arterial)\n 7.31 units\n 12:25 PM\n CO2 (Calc) arterial\n 22 mEq/L\n 12:25 PM\n Albumin\n 3.5 g/dL\n 02:21 AM\n Calcium non-ionized\n 7.6 mg/dL\n 02:21 AM\n Phosphorus\n 2.5 mg/dL\n 02:21 AM\n Magnesium\n 1.6 mg/dL\n 02:21 AM\n ALT\n 12 IU/L\n 02:21 AM\n Alkaline Phosphate\n 70 IU/L\n 02:21 AM\n AST\n 17 IU/L\n 02:21 AM\n WBC\n 20.3 K/uL\n 02:21 AM\n Hgb\n 10.8 g/dL\n 02:21 AM\n Hematocrit\n 32.7 %\n 02:21 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft, hypoactive bowel sounds, (+) flatus\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO, CA\n Estimated Nutritional Needs\n Calories: 1525-1830 (25-30 cal/kg)\n Protein: 73-85 (1.2-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: unknown\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n 38 YO female presented with sharp chest pain, fever, hypotension at\n outside hospital. CTA ruled out PE. CT showed LLL infiltrate versus\n mass . Transferred to for spine MRI. Went for a thoracic spine\n MRI, though developed an anaphylaxis reaction to receiving gadolinium\n and ultimately was intubated.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate:\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2159-11-16 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 488777, "text": "Subjective\n unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 74 kg\n 27.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 131%\n 61 kg\n Diagnosis: PNA\n PMHx: Lung Cancer, Primary\n Cervical Cancer\n Thyroid Cancer\n Depression\n Irritable Bowel Syndrome\n Food allergies and intolerances: mushrooms\n Pertinent medications: Fentanyl drip, Versed drip, normal saline @\n 10ml/hr, ABX, Pantoprazole, Colace, Magnesium sulfate (2g repletion)\n Labs:\n Value\n Date\n Glucose\n 117 mg/dL\n 02:21 AM\n BUN\n 6 mg/dL\n 02:21 AM\n Creatinine\n 0.6 mg/dL\n 02:21 AM\n Sodium\n 141 mEq/L\n 02:21 AM\n Potassium\n 4.0 mEq/L\n 02:21 AM\n Chloride\n 112 mEq/L\n 02:21 AM\n TCO2\n 22 mEq/L\n 02:21 AM\n PO2 (arterial)\n 89. mm Hg\n 12:25 PM\n PCO2 (arterial)\n 41 mm Hg\n 12:25 PM\n pH (arterial)\n 7.31 units\n 12:25 PM\n CO2 (Calc) arterial\n 22 mEq/L\n 12:25 PM\n Albumin\n 3.5 g/dL\n 02:21 AM\n Calcium non-ionized\n 7.6 mg/dL\n 02:21 AM\n Phosphorus\n 2.5 mg/dL\n 02:21 AM\n Magnesium\n 1.6 mg/dL\n 02:21 AM\n ALT\n 12 IU/L\n 02:21 AM\n Alkaline Phosphate\n 70 IU/L\n 02:21 AM\n AST\n 17 IU/L\n 02:21 AM\n WBC\n 20.3 K/uL\n 02:21 AM\n Hgb\n 10.8 g/dL\n 02:21 AM\n Hematocrit\n 32.7 %\n 02:21 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft, hypoactive bowel sounds, (+) flatus\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO, CA\n Estimated Nutritional Needs\n Calories: 1525-1830 (25-30 cal/kg)\n Protein: 73-92 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: unknown\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n 38 YO female presented with sharp chest pain, fever, hypotension at\n outside hospital. CTA ruled out PE. CT suggestive of pulmonary\n infection versus new mass as source of sepsis. Transferred to \n for MRI. Went for a thoracic spine MRI, though developed an\n anaphylaxis reaction to receiving gadolinium and ultimately was\n intubated. Remains intubated/sedated. OGT clamped. Noted low phos.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: continue\n NPO\n If unable to extubate and begin po diet within 2-3 days,\n recommend enteral nutrition\n 1. Tube feeding recommendations: Replete with Fiber @ 15ml/hr,\n advance as tolerated to goal of 65ml/hr = 1560 calories and 97g protein\n 1. Check residuals, hold tube feed if greater than 200ml\n 2. Multi-vitamin via tube feed\n Check chemistry 10 panel daily\n Replete phos\n Will follow, page if questions *\n" }, { "category": "Nursing", "chartdate": "2159-11-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488930, "text": "38yo woman with a h/o depression, IBS, ? tobacco\n use, primary thyroid cancer, primary cervical cancer, and primary lung\n cancer who was referred from last night\n after having presented there with cough, fever, left-sided chest and\n lateral neck pain. There was some concern, at the OSH, for an epidural\n abscess. Evaluation at the OSH revealed a new LLL mass / opacity of\n unclear etiology. She did not have PE or aortic dissection. She was\n sent here for possible spine MRI. In the MRI she apparently developed\n wheezing and hypoxia after having received gad. She was treated for\n anaphylaxis and was eventually intubated for persistent hypoxia. She\n was started in the ED for hypotension with Levophed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is alert and oriented x3 but sleeps in between conversation and\n arousable to voice. Slept through night.\n Action:\n Vitals remained stable. Cont on abx. Blood culture sent in AM. O2\n weaned to nasal canula 4lit, received resp treatment, Sating mid 90\n Expectorates yellow thick sputum\n Response:\n Pending\n Plan:\n Encourage pt to cough and deep breathe. Follow up with bronch, and\n blood culture results.\n" }, { "category": "Physician ", "chartdate": "2159-11-16 00:00:00.000", "description": "MICU attending", "row_id": 488666, "text": "TITLE: ICU Attending Critical Care Note\n Chart reviewed, pt examined, case discussed in detail. I was present\n for all key services delivered. For full details, please refer to\n resident note. In addition I would add/emphasize:\n 38F h/o multiple primary cancers including lung cancer, thyroid and\n cervical (all unknown type) presented to OSH w/ c/o sharp CP radiating\n to Lt shoulder, cervical neck pain, fever, hypotension. CTA r/o PE,\n dissection showed LLL infiltrate vs. mass. ED to ED transfer presumed\n for MRI. Little available in terms of records since receives care at\n OSH. VS 74/42, 109, 18, 97% 4LNC. Rt femoral line placed, Levophed\n started after had received 5L IVF w/o resolution of hypotension,\n covered broadly with abx, sent to MRI to r/o epidural abscess given\n neck pain. Had allergic reaction to gad. 0.3mg epi, 125mg solumedrol\n given. Remained with inc work of breathing so intubated. Continued\n to require Levophed for BP support. Transferred to MICU for close\n hemodyn monitoring.\n Exam:\n Intubated, sedated\n Skin warm\n Lungs\n rales in bases\n CV 2/6 SEM\n Ext pulses intact, no edema, warm\n Data:\n WBC 20.2 90%polys, no bands\n Hct 35.8\n Plt 268\n Lactate 0.8\n BUN 6\n Creat 0.6\n HCO3\n ABG: 7.19/52/17\n Mixed venous sat 70%\n CT\n Rounded homogenous infiltrate in central left lower lung field and\n fissure appearing most c/w atelectasis/collapse but cannot exclude\n mass. Appearance, location, distribution less typical for pneumonia.\n Could be loculated effusion but less dense than expected. Cannot\n exclude mass. RUL chronic appearing changes\n CXR\n ETT, RUL chronic appearing changes. No clear infiltrate or\n failure\n AP/\n 38F with history of multiple primary cancers and minimal available\n records transferred from OSH with apparent sepsis with presumed lung\n source. Intubated, on pressors.\n Presumed sepsis\n -SIRS, WBC, fever\n -CT abnormality which could be pneumonia but atypical in appearance so\n need to actively exclude other potential sources\n -MRI r/o epidural abscess T+C spine\n -abd CT OSH negative per report\n -urine clean\n -broad spectrum abx pending id of source. Is pen allergic.\n -cannot exclude meningitis though no clear history other than mild\n headache. Would likely need CT head prior to LP. Gather additional\n info & data. If no clear source, consider LP to r/o meningitis.\n Hypotension\n -requiring Levophed\n -cont aggressive fluid resuscitation\n Respiratory failure\n -presumed bronchospasm from anaphylaxis\n -no new infiltrate or evidence of flash pulm edema on CXR\n -check dynamic airway resistance on vent\n if significantly elevated,\n supports working dx\n -good chance will be able to extubate once acute anaphylaxis event\n over.\n Anaphylaxis\n -from gad contrast for MRI\n -steroids on board\n -clinically appears to be resolving\n For remainder of plan, please see resident note.\n Patient is critically ill.\n Time spent on care: 55min\n" }, { "category": "Radiology", "chartdate": "2159-11-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100679, "text": " 1:00 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?tube placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman s/p intubation\n REASON FOR THIS EXAMINATION:\n ?tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 38-year-old female status post intubation. Evaluate ET tube\n placement.\n\n Single AP chest radiograph compared to shows placement of ET tube\n which terminates 2.9 cm above the carina. Feeding tube enters the stomach.\n Left lower lobe consolidation has increased in density since the last exam.\n Opacity along the medial right upper lobe in the region of prior sugery\n correlates to a region of paramediastinal fibrosis, pleural thickening/fluid\n on CT. The heart size, hilar contours, and pulmonary vascularity are normal.\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2115-01-06 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 507273, "text": "TITLE:\n Chief Complaint: altered mental status\n HPI:\n 81F with dementia, chronic saccral decubitus ulcer to the bone on long\n term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD,\n PVD, and ESRD on HD admitted from home for altered mental status. She\n is barely verbal but responsive at baseline, but became transiently\n unresponsive the morning of admission when transport came to take her\n to HD. She was taken to the ED at where her initial vital signs were\n 98.0 94/60 66 15 96% on RA. A stat CT head showed a new parietotemporal\n hypodensity consistent with acute CVA. Neurology was consulted. She\n then became hypotensive to 68/50. She was bolused 1L NS, given pip-tazo\n and cipro for double coverage of Pseudomonas. She was not given an\n additional dose of vancomycin or other Gram positive coverage. A\n subclavian line was placed and she was sent for a torso CT to eval for\n sites of infection. The CT showed her known saccral decubitus ulcer\n tracking to the bone, a new fluid collection over the R greater\n trochanter, and a newly notes renal lesion concerning for RCC. Her BP\n stabilized after fluid bolus and she was never on pressors. General\n surgery and orthopedic surgery were consulted regarding her saccral and\n trochanteric processes and she was admitted to the MICU service.\n .\n On the floor she is A and O x 2 to person and place, and barely verbal.\n Per her sister who was at the bedside, she is at her baseline at this\n point. She denies pain, fevers, chills, or sweats. Her she is somewhat\n dysarthric but is normally so.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy, dementia\n Allergies:\n Lisinopril\n hyperkalemia at\n Verapamil\n Nausea/Vomiting\n Beta-Adrenergic Agents\n bradycardia;\n Captopril\n elevated potass\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n - Lanthanum 250 mg PO BID\n - Psyllium 1.7 g Wafer PO BID\n - Calcitonin 200 unit/Actuation Aerosol Nasal DAILY\n - Captopril 37.5 mg PO TID\n - Insulin Glargine 14 SQ DAILY plus HISS\n - Aspirin 81 mg PO DAILY\n - Heparin 5,000 units SQ \n - Methimazole 10 mg PO DAILY\n - Simvastatin 20 mg PO QHS\n - Cipro 750 mg PO DAILY, give after HD on HD days for 6 weeks\n - Flagyl 500 mg PO TID for 6 weeks\n - Labetalol 200 mg PO BID (taking as TID)\n - Ascorbic Acid 500 mg PO BID for 10 days ( to 19/09)\n - Vitamin A 20,000 units PO DAILY\n - Polyvinyl Alcohol-Povidone 1.4-0.6% Ophthalmic PRN: eye pain\n - B Complex-Vitamin C-Folic Acid PO DAILY\n - Vancomycin 1,000 IV QHD protocol for 6 weeks\n Past medical history:\n Family history:\n Social History:\n - Multiple admissions for toxic metabolic encephalopathy- extensively\n worked up with MRI, EEG, and neurologic consultations. These episodes\n are typically secondary to infections, missed dialysis sessions or\n other metabolic derrangements, and are quite profound clinically.\n - Type 2 Diabetes with labile blood surgars\n - Coronary artery disease\n - Peripheral vascular disease\n - Hypertension\n - Pulmonary hypertension\n - h/o subdural hematoma and intracranial hemorrhage in and\n neurosurgery in \n - Toxic Multinodular Goiter\n - Chronic kidney disease on HD (Tues/ Thurs/ Sat)\n - Lumbar disc disease\n - Osteoarthritis\n - Anemia - low iron and EPO\n - s/p Breast biopsy\n - s/p Hysterectomy\n - s/p transmetatarsal amputation (right foot)\n - Saccral decubitus with possible osteomyelitis. On 6 week course of\n vanco/cipro/flagyl starting on \n - Diabetes (sister)\n - Cancer in brothers and father (leukemia, prostate)\n Occupation:\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: - Has been in and out of various longterm care facilities and\n rehabs since admission in . Prior to patient was ambulatory\n with walker and could feed herself; but has not been ambulatory since\n that time. As of living at home with VNA. At baseline, she is not\n confused (as per sister) but in normally barely verbal.\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denies\n cough, shortness of breath, or wheezing. Denies chest pain, chest\n pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea,\n constipation, abdominal pain, or changes in bowel habits. Denies\n dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies\n rashes or skin changes.\n Flowsheet Data as of 10:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 68 (68 - 79) bpm\n BP: 69/31(41) {69/31(41) - 109/52(66)} mmHg\n RR: 19 (19 - 25) insp/min\n SpO2: 100%\n CVP: 3 (3 - 5)mmHg\n Total In:\n 900 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 900 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n GEN: Ill appearing elderly woman in NAD\n HEENT: MMM, no OP lesions, dentures in place, face is symmetric, no\n cervical LAD, enlarged thyroid\n CV: RR, III/VI early systolic murmur\n PULM: CTAB no wheezes or rhonchi\n ABD: BS+, NTND, no masses or HSM\n LIMSB: no toes on the R foot, wasted limbs, contractures, resting\n tremors\n SKIN: 5cm saccral decubitus to the bone and tracking under the skin\n NEURO: A and O x 2, pupils symmetric and minimially reactive, reflexes\n 3+ of the RUE and 1+ of LUE and bilat \n / Radiology\n COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [1] 01:50PM\n 10.9\n 3.86*\n 9.6*\n 33.4*\n 87\n 25.0*\n 28.8*\n 19.8*\n 328\n [2] 12:00PM\n 14.4*#\n 4.21\n 10.3*\n 37.5\n 89\n 24.4*\n 27.4*\n 19.8*\n 325\n [3] 05:40AM\n 6.9\n 3.67*\n 9.1*\n 31.9*\n 87\n 24.8*\n 28.6*\n 18.7*\n 293\n RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [4] 01:50PM\n 45*[1]\n 49*\n 3.9*#\n 149*\n 3.6\n 105\n 34*\n 14\n [5] 05:40AM\n 87\n 17\n 2.8*#\n 144\n 3.7\n 103\n 33*\n 12\n ENZYMES & BILIRUBIN\n ALT\n AST\n LD(LDH)\n CK(CPK)\n AlkPhos\n Amylase\n TotBili\n DirBili\n [6] 12:00PM\n 37\n 51*\n 145*\n 0.5\n [7][image001.gif] CHEMISTRY\n TotProt\n Albumin\n Globuln\n Calcium\n Phos\n Mg\n UricAcd\n Iron\n [8] 01:50PM\n 10.7*\n 3.2\n 2.1\n [9] 05:40AM\n 10.1\n 3.1\n 2.0\n Images:\n CT HEAD W/O CONTRAST Study Date of 12:48 PM Preliminary Report\n !! WET READ !! New hypodensity RIGHT temporo-parietal region\n concerning for an acute infarct ? watershed.\n .\n CT TORSE W/CONTRAST Study Date of 12:16 PM Preliminary Report\n !! WET READ !! Sacral ulcer extends to bone with probable signs of\n osteomyelitis. 3 x 1 cm fluid collection adj to right greater\n trochanter is new may be inflamatory or traumatic. PUlm nodules f/u in\n 3 months ? 8mm right renal enhancing lesion.\n Assessment and Plan\n 81F with dementia, chronic saccral decubitus ulcer to the bone on long\n term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD,\n PVD, and ESRD on HD admitted from home for altered mental status. CT\n showed likely new CVA. Saccral wound seems similar to past. New\n findings include possible trochanteric bursitis versus abscess,\n possible RCC, and large thyroid mass palpable on exam and visable on\n CT. She had a brief hypotensive event in the ED but is HD stable since.\n She also has been taking extra doses of labetalol at home.\n .\n # Altered mental status: Likely due to new CVA. Seems to have resolved\n to some degree at this point. Also could be due to hypotension from\n extra dose of labetalol. Infection can also cause a neurologicla\n decompensation.\n - Neurology consulting. Recommendations appreciated\n - Continue home simvastatin\n - Increase ASA to 325mg PO daily\n - Infectious workup with BCx and wound Cx\n - Monitor on tele\n - TSH, B12, and folic acid pending\n .\n # Saccral decubitus: Chronic. Per sister is stable to improved.\n - Surgery following. Recommendations appreciated\n - Orthopedics following. Recommendations appreciated\n - Continue wet to dry dressings\n - Have patient in a KinAir bed\n - Broaden cipro / flagyl to pip/tazo 2.25mg IV Q6H\n - Continue vancomycin 1g IV QHD\n - Wound Cx pending\n .\n # Trochanteric collection: Looks like bursitis on CT. No overlying skin\n breakdown or tenderness.\n - Orthopedics following. Recommendations appreciated.\n - IR guided aspiration in the AM\n .\n # New CVA: CT showed new R parietotemoral CVA.\n - Neurology consulting. Recommendations appreciated.\n - Increase ASA to 325mg PO daily\n - Continue simvastatin 20mg PO HS\n - Will obtain MRI MRA of the head and neck once stable\n - Monitor on tele for Afib\n - Will obtain ECHO in the AM\n - Allow BPs to autoregular between 120 to 160 SBP\n .\n # Thyroid mass: Seen on physical exam and CT.\n - Thyroid US and possible Bx pending\n .\n # ESRD: Renal aware Pt admitted.\n - Hold HD until BP stabilized\n - Continue Calcitonin Salmon 200 UNIT NAS DAILY\n - Continue Lanthanum 250 mg PO/NG \n .\n # Diabetes: Continue glargine and HISS\n .\n # FEN: No IVF, replete electrolytes per renal, continue tube feeds\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n # Access: R subclavian, PIV, femoral HD line\n # Communication: \n # Code: Full (discussed with HCP \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 07:17 PM\n Multi Lumen - 07:18 PM\n 18 Gauge - 07:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 81 y/o, female, base line dementia, chronic\n sacral decubitus ulcer with osteomyelitis, CAD, PVD, HTN, DM, ESRD on\n HD (anuric). Presents with altered mental status, non-verbal, Head CT\n in in the ED with new right temporoparietal CVA, become hypotensive,\n was started on IVF's and antibiotics. CT torso with multiple\n abnormalities left trochanteric fluid collection but no signs of\n abscess.\n Exam notable for Tm BP HR RR with sat on . Labs notable for WBC K, Hgb\n 9.6, K+ , Cr , lactate. CXR with , EKG .\n Agree with plan to continue with antibiotics (Vancomycin and Zosyn),\n monitor vital signs, follow CVP, follow BP with goal 120-160 SBP, neuro\n checks, follow-up with surgery, orthopedic surgery, and neurology.\n MRI/MRA of the head when stable, aspiration of trochanteric collection.\n Remainder of plan as outlined above.\n ------ Protected Section Addendum Entered By: , MD\n on: 05:57 ------\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_1%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n 4. JavaScript:parent.POPUP(self,%22_WEBTAG=_42%22);\n 5. JavaScript:parent.POPUP(self,%22_WEBTAG=_43%22);\n 6. JavaScript:parent.POPUP(self,%22_WEBTAG=_63%22);\n 7. javascript:command('LCBI','expand')\n 8. JavaScript:parent.POPUP(self,%22_WEBTAG=_64%22);\n 9. JavaScript:parent.POPUP(self,%22_WEBTAG=_65%22);\n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 507378, "text": "Pt is an 81 yo female with PMH: DM-2, glargine hs and Humalog SS; ESRD\n on HD;Multiple falls; sacral osteomyelitis on vanco/cipro/flagyl;\n falls; SDH; PVD; HTN; multiple admissions for encephalopathy\n secondary to infections or missed HD.\n Pt lives at home with her sister who is her caretaker. Adm to\n with MS changes. Was enroute to HD, when medics noted\n altered MS, taken to EW. In EW, SBP 90\ns, received 1L fluid, started\n on Zosyn and TLC placed. ? if patient had been receiving extra doses of\n Labetolol at home. Head CT with new stroke, ? several days old. CT\n torso\nsacral decube to bone, improving. Sent to CCU (MICU service)\n for monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Both arms severely contracted. Dose not follow commands. When asked\n to open mouth for oral temp, sqeezes mouth tightly shut. Does open her\n mouth for oral care. Today, said good morning to RN, no other verbal\n interaction, not answering questions. Last night was able to state\n place and time. Her sister said that this is how she is at\n home\nsometimes verbally responsive, sometimes not. Unable to assess\n pupils today as pt. sqeezing eyes closed with attempts, but have been\n equal previous shifts. Pt nods head very slightly for yes/no. Moves\n all extremities with painful stimuli, but not purposefully.\n Action/Response:\n Pt reoriented\n Plan:\n Continue to monitor mental status, reorient.\n Impaired Skin Integrity\n Assessment:\n R foot with all toes amputated. 7 X3 cm Sacral Decube, stage IV with\n an adjacent stage II decube. Receiving wet to dry dressing ,\n surgery is following. T max 99.8 rectally.\n Action/Response:\n Wet to dry dressing change done @1100, mod amount serous\n drainage, no odor.\n To receive vanco/cipro with dialysis\n Plan:\n wet to dry dressing change to ducube. Pt on kinair bed, reposition\n q 2hours. Receiving TF via peg\n Hypotension (not Shock)\n Assessment:\n CVP 4-5, SBP 100-120. NBP placed on Left thigh for BP\ns (arms\n contracted). HR 80\ns sinus rhythm, also had one 28 beat run of SVT,\n rate of 180. Broke spontanteously\nMICU team notified--this is not new\n as per MICU resident. Labetolol is on hold. Lungs clear, sats 98% on\n RA.\n Action/Response:\n BP monitored\n HR/Rhythm monitored\n Plan:\n Continue to monitor HR/Rhythm/BP. Next dialysis Monday as per team.\n GI: Novasource TF via peg, goal rate 35 cc/hour, currently @ 30\n cc/hour, ^ to 35 cc/hour at 1600. 12noon BS 122\n2 Units Humalog, BS\n checks q 4 hours. Abd soft, soft brown stool this am.\n Access: R SC TLC, #18 R PIV.\n HCP: sister : \n \n Attending MD:\n \n Admit diagnosis:\n SYNCOPE;TELEMETRY\n Code status:\n Height:\n Admission weight:\n 62.5 kg\n Daily weight:\n 64.6 kg\n Allergies/Reactions:\n Lisinopril\n hyperkalemia at\n Verapamil\n Nausea/Vomiting\n Beta-Adrenergic Agents\n bradycardia;\n Captopril\n elevated potass\n Precautions:\n PMH: Diabetes - Insulin, HEMO or PD, Renal Failure\n CV-PMH: CAD, Hypertension, PVD\n Additional history: Multiple admissions for toxic metabolic\n encephalopathy- extensively worked up with MRI, EEG, and neurologic\n consultations. These episodes are typically secondary to infections,\n missed dialysis sessions or other metabolic derrangements, and are\n quite profound clinically.\n - Type 2 Diabetes Mellitus with labile blood surgars\n - Coronary artery disease\n - Peripheral vascular disease\n - Hypertension\n - Pulmonary hypertension\n - h/o subdural hematoma and intracranial hemorrhage in and\n neurosurgery in \n - Toxic Multinodular Goiter\n - Chronic kidney disease on HD (Tues/ Thurs/ Sat)\n - Lumbar disc disease\n - Osteoarthritis\n - Anemia - low iron and EPO\n - s/p Breast biopsy\n - s/p Hysterectomy\n - s/p transmetatarsal amputation (right foot)\n - Saccral decubitus with possible osteomyelitis. On 6 week course of\n vanco/cipro/flagyl starting on \n Surgery / Procedure and date: Full body scan revealed possible\n osteomylitis w/ sacral wound extending to bone reportedly. ? possible\n stroke given new acute infact seen on scan. New lesion on kidney.\n Lactate nl, inr nl,\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:52\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 28 insp/min\n Heart Rate:\n 75 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,076 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 146 mEq/L\n 02:51 AM\n Potassium:\n 3.7 mEq/L\n 02:51 AM\n Chloride:\n 105 mEq/L\n 02:51 AM\n CO2:\n 31 mEq/L\n 02:51 AM\n BUN:\n 50 mg/dL\n 02:51 AM\n Creatinine:\n 4.1 mg/dL\n 02:51 AM\n Glucose:\n 115 mg/dL\n 02:51 AM\n Hematocrit:\n 29.9 %\n 02:51 AM\n Finger Stick Glucose:\n 122\n 12:00 PM\n Valuables / Signature\n Patient valuables: upper and lower dentures\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: ccu\n Transferred to: 2\n Date & time of Transfer: , 1530\n" }, { "category": "Physician ", "chartdate": "2115-01-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 507366, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 07:17 PM\n Tunneled\n MULTI LUMEN - START 07:18 PM\n Allergies:\n Lisinopril\n hyperkalemia at\n Verapamil\n Nausea/Vomiting\n Beta-Adrenergic Agents\n bradycardia;\n Captopril\n elevated potass\n Last dose of Antibiotics:\n Piperacillin - 10:37 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 81 (68 - 81) bpm\n BP: 101/48(60) {69/31(41) - 109/52(67)} mmHg\n RR: 22 (18 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (3 - 5)mmHg\n Total In:\n 1,003 mL\n 707 mL\n PO:\n TF:\n 3 mL\n 7 mL\n IVF:\n 50 mL\n 600 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,003 mL\n 707 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n GEN- nad, opens eyes to command, non-verbal.\n HEENT\n asymmetric eyes and lips and cheeks.\n CV\n soft heart sounds, no murmurs appreciated\n PULM\n ctab but without significant respiratory effort\n ABD\n soft, distended, non-tender\n EXTR\n no edema; no ttp at right hip\n SKIN\n sacral ulcer extremely deep, pink, granulation tissue\n Labs / Radiology\n 253 K/uL\n 8.7 g/dL\n 115 mg/dL\n 4.1 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 50 mg/dL\n 105 mEq/L\n 146 mEq/L\n 29.9 %\n 9.5 K/uL\n [image002.jpg]\n 02:51 AM\n WBC\n 9.5\n Hct\n 29.9\n Plt\n 253\n Cr\n 4.1\n Glucose\n 115\n Other labs: PT / PTT / INR:13.1/26.8/1.1, ALT / AST:26/25, Alk Phos / T\n Bili:120/0.2, Albumin:2.7 g/dL, LDH:149 IU/L, Ca++:9.6 mg/dL, Mg++:2.1\n mg/dL, PO4:3.6 mg/dL\n No new micro\n CXR:\n FINDINGS: AP upright portable chest radiograph is obtained. The right\n subclavian central venous catheter now terminates in the expected\n location of the superior vena cava, retracted from its previous\n position of the right atrium. The catheter extending up from the IVC is\n unchanged and terminates in the right atrium. Multiple vascular stents\n are again noted. The lungs remain\n clear.\n IMPRESSION: Improved position of right subclavian catheter. Otherwise,\n no change.\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n 81F with dementia, chronic saccral decubitus ulcer to the bone on long\n term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD,\n PVD, and ESRD on HD admitted from home for altered mental status. CT\n showed likely new CVA. Saccral wound seems similar to past. New\n findings include possible trochanteric bursitis versus abscess,\n possible RCC, and large thyroid mass palpable on exam and visable on\n CT. She had a brief hypotensive event in the ED but is HD stable since.\n She also has been taking extra doses of labetalol at home.\n .\n # Altered mental status: Likely due to new CVA. Seems to have resolved\n to some degree at this point. Also could be due to hypotension from\n extra dose of labetalol. Infection can also cause a neurological\n decompensation.\n - Neurology consulting. Recommendations appreciated\n - Continue home simvastatin\n - Increased ASA to 325mg PO daily\n - Infectious workup with BCx and wound Cx\n - Monitor on tele\n - TSH, B12, and folic acid pending\n - f/u CT head final read\n .\n # Saccral decubitus: Chronic. Per sister is stable to improved.\n - Surgery following. Recommendations appreciated\n - Orthopedics following. Recommendations appreciated\n - Continue wet to dry dressings\n - Have patient in a KinAir bed\n - d/c zosyn and return to cipro/flagyl coverage\n - Continue vancomycin 1g IV QHD\n - Wound Cx pending\n - f/u CT torso final read\n .\n # Trochanteric collection: Looks like bursitis on CT. No overlying skin\n breakdown or tenderness.\n - Orthopedics following. Recommendations appreciated.\n - IR guided aspiration\n .\n # New CVA: CT showed new R parietotemoral CVA.\n - f/u final read CT head\n - Neurology consulting. Recommendations appreciated.\n - Increased ASA to 325mg PO daily\n - Continue simvastatin 20mg PO HS\n - Will obtain MRI/MRA of the head and neck once stable\n - Monitor on tele for Afib\n - Will obtain ECHO tomorrow\n - Allow BPs to auto-regulate between 120 to 160 SBP\n .\n # Thyroid mass: Seen on physical exam and CT.\n - Thyroid US and possible Bx pending\n .\n # Nodules seen on chest CT:\n - f/u as outpatient with repeat CT scan\n .\n # ESRD: Renal aware Pt admitted.\n - Hold HD until BP stabilized\n - Continue Calcitonin Salmon 200 UNIT NAS DAILY\n - Continue Lanthanum 250 mg PO/NG \n .\n # Diabetes: Continue glargine and HISS\n .\n # FEN: No IVF, replete electrolytes per renal, continue tube feeds\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n # Access: R subclavian, PIV, femoral HD line\n # Communication: \n # Code: Full (discussed with HCP \n # Disposition: Call-out to the floor today.\n ICU Care\n Lines:\n Dialysis Catheter - 07:17 PM\n Multi Lumen - 07:18 PM\n 18 Gauge - 07:21 PM\n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507359, "text": "Pt is an 81 yo female with PMH: DM-2, glargine hs and Humalog SS; ESRD\n on HD;Multiple falls; sacral osteomyelitis on vanco/cipro/flagyl;\n falls; SDH; PVD; HTN; multiple admissions for encephalopathy\n secondary to infections or missed HD.\n Pt lives at home with her sister who is her caretaker. Adm to\n with MS changes. Was enroute to HD, when medics noted\n altered MS, taken to EW. In EW, SBP 90\ns, received 1L fluid, started\n on Zosyn and TLC placed. ? if patient had been receiving extra doses of\n Labetolol at home. Head CT with new stroke, ? several days old. CT\n torso\nsacral decube to bone, improving. Sent to CCU (MICU service)\n for monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Both arms severely contracted. Dose not follow commands. When asked\n to open mouth for oral temp, sqeezes mouth tightly shut. Does open her\n mouth for oral care. Today, said good morning to RN, no other verbal\n interaction, not answering questions. Last night was able to state\n place and time. Her sister said that this is how she is at\n home\nsometimes verbally responsive, sometimes not. Unable to assess\n pupils today as pt. sqeezing eyes closed with attempts, but have been\n equal previous shifts. Pt nods head very slightly for yes/no. Moves\n all extremities with painful stimuli, but not purposefully.\n Action/Response:\n Pt reoriented\n Plan:\n Continue to monitor mental status, reorient.\n Impaired Skin Integrity\n Assessment:\n R foot with all toes amputated. 7 X3 cm Sacral Decube, stage IV with\n an adjacent stage II decube. Receiving wet to dry dressing ,\n surgery is following. T max 99.8 rectally.\n Action/Response:\n Wet to dry dressing change done @1100, mod amount serous\n drainage, no odor.\n To receive vanco/cipro with dialysis\n Plan:\n wet to dry dressing change to ducube. Pt on kinair bed, reposition\n q 2hours. Receiving TF via peg\n Hypotension (not Shock)\n Assessment:\n CVP 4-5, SBP 100-120. NBP placed on Left thigh for BP\ns (arms\n contracted). HR 80\ns sinus rhythm, also had one 28 beat run of SVT,\n rate of 180. Broke spontanteously\nMICU team notified--this is not new\n as per MICU resident. Labetolol is on hold. Lungs clear, sats 98% on\n RA.\n Action/Response:\n BP monitored\n HR/Rhythm monitored\n Plan:\n Continue to monitor HR/Rhythm/BP. Next dialysis Monday as per team.\n GI: Novasource TF via peg, goal rate 35 cc/hour, currently @ 30\n cc/hour, ^ to 35 cc/hour at 1600. 12noon BS 122\n2 Units Humalog, BS\n checks q 4 hours. Abd soft, soft brown stool this am.\n Access: R SC TLC, #18 R PIV.\n HCP: sister : \n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 507360, "text": "Pt is an 81 yo female with PMH: DM-2, glargine hs and Humalog SS; ESRD\n on HD;Multiple falls; sacral osteomyelitis on vanco/cipro/flagyl;\n falls; SDH; PVD; HTN; multiple admissions for encephalopathy\n secondary to infections or missed HD.\n Pt lives at home with her sister who is her caretaker. Adm to\n with MS changes. Was enroute to HD, when medics noted\n altered MS, taken to EW. In EW, SBP 90\ns, received 1L fluid, started\n on Zosyn and TLC placed. ? if patient had been receiving extra doses of\n Labetolol at home. Head CT with new stroke, ? several days old. CT\n torso\nsacral decube to bone, improving. Sent to CCU (MICU service)\n for monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Both arms severely contracted. Dose not follow commands. When asked\n to open mouth for oral temp, sqeezes mouth tightly shut. Does open her\n mouth for oral care. Today, said good morning to RN, no other verbal\n interaction, not answering questions. Last night was able to state\n place and time. Her sister said that this is how she is at\n home\nsometimes verbally responsive, sometimes not. Unable to assess\n pupils today as pt. sqeezing eyes closed with attempts, but have been\n equal previous shifts. Pt nods head very slightly for yes/no. Moves\n all extremities with painful stimuli, but not purposefully.\n Action/Response:\n Pt reoriented\n Plan:\n Continue to monitor mental status, reorient.\n Impaired Skin Integrity\n Assessment:\n R foot with all toes amputated. 7 X3 cm Sacral Decube, stage IV with\n an adjacent stage II decube. Receiving wet to dry dressing ,\n surgery is following. T max 99.8 rectally.\n Action/Response:\n Wet to dry dressing change done @1100, mod amount serous\n drainage, no odor.\n To receive vanco/cipro with dialysis\n Plan:\n wet to dry dressing change to ducube. Pt on kinair bed, reposition\n q 2hours. Receiving TF via peg\n Hypotension (not Shock)\n Assessment:\n CVP 4-5, SBP 100-120. NBP placed on Left thigh for BP\ns (arms\n contracted). HR 80\ns sinus rhythm, also had one 28 beat run of SVT,\n rate of 180. Broke spontanteously\nMICU team notified--this is not new\n as per MICU resident. Labetolol is on hold. Lungs clear, sats 98% on\n RA.\n Action/Response:\n BP monitored\n HR/Rhythm monitored\n Plan:\n Continue to monitor HR/Rhythm/BP. Next dialysis Monday as per team.\n GI: Novasource TF via peg, goal rate 35 cc/hour, currently @ 30\n cc/hour, ^ to 35 cc/hour at 1600. 12noon BS 122\n2 Units Humalog, BS\n checks q 4 hours. Abd soft, soft brown stool this am.\n Access: R SC TLC, #18 R PIV.\n HCP: sister : \n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507203, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt was able to speak with one word responses oriented x3 at beginning\n of night pt became more lethargic and by midnight pt was very difficult\n to arouse pt was unable to answer questions. ? stroke given new acute\n infarct on ct scan\n Action:\n Pt aroused q hour assessing mental status\n Response:\n Pt very lethargic too difficult to stay awake to answer questions\n Plan:\n Continue to assess mental status\n Hypotension (not Shock)\n Assessment:\n Bp low sys 90\ns-100\n Action:\n Antibiotics and 500cc NS bolus\n Response:\n Pt responded well to bolusus increased bp\n Plan:\n Continue to assess bp hr rhythm, obtain cultures assess temp monitor\n for signs of sepsis\n Impaired Skin Integrity\n Assessment:\n Sacrum ulcer\n Action:\n MD in to assess removed dressing ulcer clean healing MD\n Response:\n dressing changes wet to dry\n Plan:\n Assess for pain change position frequently\n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507341, "text": "Pt is an 81 yo female with PMH: DM-2, glargine hs and Humalog SS; ESRD\n on HD;Multiple falls; sacral osteomyelitis on vanco/cipro/flagyl;\n falls; SDH; PVD; HTN; multiple admissions for encephalopathy\n secondary to infections or missed HD.\n Pt lives at home with her sister who is her caretaker. Adm to\n with MS changes. Was enroute to HD, when medics noted\n altered MS, taken to EW. In EW, SBP 90\ns, received 1L fluid, started\n on Zosyn and TLC placed. ? if patient had been receiving extra doses of\n Labetolol at home. Head CT with new stroke, ? several days old. CT\n torso\nsacral decube to bone, improving. Sent to CCU (MICU service)\n for monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Both arms severely contracted. Dose not follow commands. When asked\n to open mouth for oral temp, sqeezes mouth tightly shut. Does open her\n mouth for oral care. Today, said good morning to RN, no other verbal\n interaction, not answering questions. Last was able to state place and\n time. Her sister said that this is how she is at\n home\nsometimes verbally responsive, sometimes not. Unable to assess\n pupils today as pt. sqeezing eyes closed with attempts, but have been\n equal previous shifts.\n Action/Response:\n Pt reoriented\n Plan:\n Impaired Skin Integrity\n Assessment:\n R foot with all toes amputated. 7 X3 cm Sacral Decube, stage IV with\n an adjacent stage II decube. Receiving wet to dry dressing ,\n surgery is following. T max 99.8 rectally.\n Action/Response:\n Wet to dry dressing change done @1100, mod amount serous\n drainage, no odor.\n To receive vanco/cipro with dialysis\n Plan:\n Hypotension (not Shock)\n Assessment:\n CVP 4-5, SBP 100-120. NBP placed on Left thigh for BP\ns (arms\n contracted). HR 80\ns sinus rhythm, also had one 28 beat run of SVT,\n rate of 180. Broke spontanteously\nMICU team notified--this is not new\n as per MICU resident. Labetolol is on hold.\n Action/Response:\n BP monitored\n HR/Rhythm monitored\n Plan:\n GI: Novasource TF via peg, goal rate 35 cc/hour. Abd soft, soft brown\n stool this am.\n Access: R SQ TLC, #18 PIV.\n" }, { "category": "Physician ", "chartdate": "2115-01-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 507318, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 07:17 PM\n Tunneled\n MULTI LUMEN - START 07:18 PM\n Allergies:\n Lisinopril\n hyperkalemia at\n Verapamil\n Nausea/Vomiting\n Beta-Adrenergic Agents\n bradycardia;\n Captopril\n elevated potass\n Last dose of Antibiotics:\n Piperacillin - 10:37 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 81 (68 - 81) bpm\n BP: 101/48(60) {69/31(41) - 109/52(67)} mmHg\n RR: 22 (18 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 5 (3 - 5)mmHg\n Total In:\n 1,003 mL\n 707 mL\n PO:\n TF:\n 3 mL\n 7 mL\n IVF:\n 50 mL\n 600 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,003 mL\n 707 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n GEN\n CV\n PULM\n ABD\n EXTR\n Labs / Radiology\n 253 K/uL\n 8.7 g/dL\n 115 mg/dL\n 4.1 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 50 mg/dL\n 105 mEq/L\n 146 mEq/L\n 29.9 %\n 9.5 K/uL\n [image002.jpg]\n 02:51 AM\n WBC\n 9.5\n Hct\n 29.9\n Plt\n 253\n Cr\n 4.1\n Glucose\n 115\n Other labs: PT / PTT / INR:13.1/26.8/1.1, ALT / AST:26/25, Alk Phos / T\n Bili:120/0.2, Albumin:2.7 g/dL, LDH:149 IU/L, Ca++:9.6 mg/dL, Mg++:2.1\n mg/dL, PO4:3.6 mg/dL\n No new micro\n CXR:\n FINDINGS: AP upright portable chest radiograph is obtained. The right\n subclavian central venous catheter now terminates in the expected\n location of the superior vena cava, retracted from its previous\n position of the right atrium. The catheter extending up from the IVC is\n unchanged and terminates in the right atrium. Multiple vascular stents\n are again noted. The lungs remain\n clear.\n IMPRESSION: Improved position of right subclavian catheter. Otherwise,\n no change.\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n 81F with dementia, chronic saccral decubitus ulcer to the bone on long\n term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD,\n PVD, and ESRD on HD admitted from home for altered mental status. CT\n showed likely new CVA. Saccral wound seems similar to past. New\n findings include possible trochanteric bursitis versus abscess,\n possible RCC, and large thyroid mass palpable on exam and visable on\n CT. She had a brief hypotensive event in the ED but is HD stable since.\n She also has been taking extra doses of labetalol at home.\n .\n # Altered mental status: Likely due to new CVA. Seems to have resolved\n to some degree at this point. Also could be due to hypotension from\n extra dose of labetalol. Infection can also cause a neurologicla\n decompensation.\n - Neurology consulting. Recommendations appreciated\n - Continue home simvastatin\n - Increase ASA to 325mg PO daily\n - Infectious workup with BCx and wound Cx\n - Monitor on tele\n - TSH, B12, and folic acid pending\n - f/u CT head final read\n .\n # Saccral decubitus: Chronic. Per sister is stable to improved.\n - Surgery following. Recommendations appreciated\n - Orthopedics following. Recommendations appreciated\n - Continue wet to dry dressings\n - Have patient in a KinAir bed\n - Broaden cipro / flagyl to pip/tazo 2.25mg IV Q6H\n - Continue vancomycin 1g IV QHD\n - Wound Cx pending\n - f/u CT torso final read\n .\n # Trochanteric collection: Looks like bursitis on CT. No overlying skin\n breakdown or tenderness.\n - Orthopedics following. Recommendations appreciated.\n - IR guided aspiration in the AM\n .\n # New CVA: CT showed new R parietotemoral CVA.\n - f/u final read CT head\n - Neurology consulting. Recommendations appreciated.\n - Increase ASA to 325mg PO daily\n - Continue simvastatin 20mg PO HS\n - Will obtain MRI/MRA of the head and neck once stable\n - Monitor on tele for Afib\n - Will obtain ECHO in the AM\n - Allow BPs to auto-regulate between 120 to 160 SBP\n .\n # Thyroid mass: Seen on physical exam and CT.\n - Thyroid US and possible Bx pending\n .\n # ESRD: Renal aware Pt admitted.\n - Hold HD until BP stabilized\n - Continue Calcitonin Salmon 200 UNIT NAS DAILY\n - Continue Lanthanum 250 mg PO/NG \n .\n # Diabetes: Continue glargine and HISS\n .\n # FEN: No IVF, replete electrolytes per renal, continue tube feeds\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n # Access: R subclavian, PIV, femoral HD line\n # Communication: \n # Code: Full (discussed with HCP \n # Disposition: ICU pending clinical improvement\n ICU Care\n Lines:\n Dialysis Catheter - 07:17 PM\n Multi Lumen - 07:18 PM\n 18 Gauge - 07:21 PM\n" }, { "category": "Physician ", "chartdate": "2115-01-06 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 507327, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 81 yo women with DM, ESRD on HD, dementia, sacral decubes. Had\n decreased MS at home. Was going to HD, but EMS diverted to ED because\n of poor MS. Initial BP in ED was 94/60. Stat head CT with new CVA.\n After head CT, became HOTNsive - got 1L IVF. Got Zosyn and cipro for\n decube coverage. Got subclavian line, and CT torso. It showed decube\n tracking to bone that is stable to improved. New right trochanteric\n fluid collection - seen by orthos - suggested IR guided mass. Also\n renal mass and pulmonary nodules.\n 24 Hour Events:\n DIALYSIS CATHETER - START 07:17 PM\n Tunneled\n MULTI LUMEN - START 07:18 PM\n Allergies:\n Lisinopril\n hyperkalemia at\n Verapamil\n Nausea/Vomiting\n Beta-Adrenergic Agents\n bradycardia;\n Captopril\n elevated potass\n Last dose of Antibiotics:\n Piperacillin - 10:37 PM\n Infusions:\n Other ICU medications:\n Other medications:\n simvastatin\n asa\n s/q heparin\n lanthinum\n calcitonin\n SSI\n methimazole\n Changes to medical and family history:\n PMHx.\n Altered MS \nSDH\n intraparenchymal hemorrhages from falls\n goiter\n chronic renal failure on HD\n chronic vanco/cipro/flagyl for sacral osteo\n ShX: lives with sister at home\n : noncontributory for dementia\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 75 (68 - 81) bpm\n BP: 107/49(60) {69/31(41) - 109/52(67)} mmHg\n RR: 22 (18 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64.6 kg (admission): 62.5 kg\n CVP: 5 (3 - 5)mmHg\n Total In:\n 1,003 mL\n 814 mL\n PO:\n TF:\n 3 mL\n 34 mL\n IVF:\n 50 mL\n 600 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,003 mL\n 814 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, Movement: Not assessed, Tone: Not assessed, stage\n IV sacral decube with granulation tissue\n Labs / Radiology\n 8.7 g/dL\n 253 K/uL\n 115 mg/dL\n 4.1 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 50 mg/dL\n 105 mEq/L\n 146 mEq/L\n 29.9 %\n 9.5 K/uL\n [image002.jpg]\n 02:51 AM\n WBC\n 9.5\n Hct\n 29.9\n Plt\n 253\n Cr\n 4.1\n Glucose\n 115\n Other labs: PT / PTT / INR:13.1/26.8/1.1, ALT / AST:26/25, Alk Phos / T\n Bili:120/0.2, Albumin:2.7 g/dL, LDH:149 IU/L, Ca++:9.6 mg/dL, Mg++:2.1\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n New CVA: As per neuro looks like a small vessel, HTNsive CVA.\n Continue asa and statin.\n HOTN: Sister may have been giving extra doses of both labetolol.\n Can't r/o sepsis, but she has improved quickly, so will change\n antibiotics back to Vanco/cipro/flagyl.\n trochanteric collection: likely bursitis, but will get IR guided\n aspiration.\n HTN: consider simplifying regimen\n lung nodules: may be scars simply needs repeat scan in few months.\n unclear what she needs for ?renal tumour- seems quite small, can maybe\n just do repeat scan in 3 months given that she is\n not likely candidat for surgery.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 08:36 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 07:17 PM\n Multi Lumen - 07:18 PM\n 18 Gauge - 07:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507334, "text": "Pt is an 81 yo female with PMH: DM-2, glargine hs and Humalog SS; ESRD\n on HD;Multiple falls; sacral osteomyelitis on vanco/cipro/flagyl;\n falls; SDH; PVD; HTN; multiple admissions for encephalopathy\n secondary to infections or missed HD.\n Pt lives at home with her sister who is her caretaker. Adm to\n with MS changes. Was enroute to HD, when medics noted\n altered MS, taken to EW. In EW, SBP 90\ns, received 1L fluid, started\n on Zosyn and TLC placed. ? if patient had been receiving extra doses of\n Labetolol at home. Head CT with new stroke, ? several days old. CT\n torso\nsacral decube to bone, improving. Sent to CCU (MICU service)\n for monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Both arms severely contracted. Dose not follow commands. When asked\n to open mouth for oral temp, sqeezes mouth tightly shut. Does open her\n mouth for oral care. Today, said good morning to RN, no other verbal\n interaction, not answering questions. Last was able to state place and\n time. Her sister said that this is how she is at\n home\nsometimes verbally responsive, sometimes not. Unable to assess\n pupils today as pt. sqeezing eyes closed with attempts, but have been\n equal previous shifts.\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n R foot with all toes amputated. Sacrum with deep stage iV decube with\n and adjacent stage II decube. Receiving wet to dry dressing ,\n surgery is following. T max 99.8 rectally.\n Action:\n Wet to dry dressing change done, mod amount serous drainage,\n no odor.\n To receive vanco/cipro with dialysis\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n CVP 4-5, SBP 100-120. HR 80\ns sinus rhythm, also had one 28 beat run\n of SVT, rate of 180. Broke spontanteously. This is not new as per\n MICU resident. Labetolol is on hold.\n Action:\n BP monitored\n HR/Rhythm monitored\n Response:\n Plan:\n GI: TF via peg\n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507348, "text": "Pt is an 81 yo female with PMH: DM-2, glargine hs and Humalog SS; ESRD\n on HD;Multiple falls; sacral osteomyelitis on vanco/cipro/flagyl;\n falls; SDH; PVD; HTN; multiple admissions for encephalopathy\n secondary to infections or missed HD.\n Pt lives at home with her sister who is her caretaker. Adm to\n with MS changes. Was enroute to HD, when medics noted\n altered MS, taken to EW. In EW, SBP 90\ns, received 1L fluid, started\n on Zosyn and TLC placed. ? if patient had been receiving extra doses of\n Labetolol at home. Head CT with new stroke, ? several days old. CT\n torso\nsacral decube to bone, improving. Sent to CCU (MICU service)\n for monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Both arms severely contracted. Dose not follow commands. When asked\n to open mouth for oral temp, sqeezes mouth tightly shut. Does open her\n mouth for oral care. Today, said good morning to RN, no other verbal\n interaction, not answering questions. Last night was able to state\n place and time. Her sister said that this is how she is at\n home\nsometimes verbally responsive, sometimes not. Unable to assess\n pupils today as pt. sqeezing eyes closed with attempts, but have been\n equal previous shifts. Pt nods head very slightly for yes/no. Moves\n all extremities with painful stimuli, but not purposefully.\n Action/Response:\n Pt reoriented\n Plan:\n Continue to monitor mental status, reorient.\n Impaired Skin Integrity\n Assessment:\n R foot with all toes amputated. 7 X3 cm Sacral Decube, stage IV with\n an adjacent stage II decube. Receiving wet to dry dressing ,\n surgery is following. T max 99.8 rectally.\n Action/Response:\n Wet to dry dressing change done @1100, mod amount serous\n drainage, no odor.\n To receive vanco/cipro with dialysis\n Plan:\n wet to dry dressing change to ducube. Pt on kinair bed, reposition\n q 2hours. Receiving TF via peg\n Hypotension (not Shock)\n Assessment:\n CVP 4-5, SBP 100-120. NBP placed on Left thigh for BP\ns (arms\n contracted). HR 80\ns sinus rhythm, also had one 28 beat run of SVT,\n rate of 180. Broke spontanteously\nMICU team notified--this is not new\n as per MICU resident. Labetolol is on hold. Lungs clear, sats 98% on\n RA.\n Action/Response:\n BP monitored\n HR/Rhythm monitored\n Plan:\n Continue to monitor HR/Rhythm/BP. Next dialysis Monday as per team.\n GI: Novasource TF via peg, goal rate 35 cc/hour, currently @ 30\n cc/hour, ^ to 35 cc/hour at 1600. 12noon BS 122\n2 Units Humalog, BS\n checks q 4 hours. Abd soft, soft brown stool this am.\n Access: R SC TLC, #18 R PIV.\n HCP: sister : \n" }, { "category": "Nursing", "chartdate": "2115-01-05 00:00:00.000", "description": "Nursing Note", "row_id": 507181, "text": "TITLE:\n Pt arrived to CCU w/ stable VS. LS clear.\n No pain. IVF kvo. IV sites occlusive w/ dressings.\n Sacral wound assessed and documented. New w->D dressing applied.\n" }, { "category": "Physician ", "chartdate": "2115-01-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 507185, "text": "TITLE:\n Chief Complaint: altered mental status\n HPI:\n 81F with dementia, chronic saccral decubitus ulcer to the bone on long\n term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD,\n PVD, and ESRD on HD admitted from home for altered mental status. She\n is barely verbal but responsive at baseline, but became transiently\n unresponsive the morning of admission when transport came to take her\n to HD. She was taken to the ED at where her initial vital signs were\n 98.0 94/60 66 15 96% on RA. A stat CT head showed a new parietotemporal\n hypodensity consistent with acute CVA. Neurology was consulted. She\n then became hypotensive to 68/50. She was bolused 1L NS, given pip-tazo\n and cipro for double coverage of Pseudomonas. She was not given an\n additional dose of vancomycin or other Gram positive coverage. A\n subclavian line was placed and she was sent for a torso CT to eval for\n sites of infection. The CT showed her known saccral decubitus ulcer\n tracking to the bone, a new fluid collection over the R greater\n trochanter, and a newly notes renal lesion concerning for RCC. Her BP\n stabilized after fluid bolus and she was never on pressors. General\n surgery and orthopedic surgery were consulted regarding her saccral and\n trochanteric processes and she was admitted to the MICU service.\n .\n On the floor she is A and O x 2 to person and place, and barely verbal.\n Per her sister who was at the bedside, she is at her baseline at this\n point. She denies pain, fevers, chills, or sweats. Her she is somewhat\n dysarthric but is normally so.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy, dementia\n Allergies:\n Lisinopril\n hyperkalemia at\n Verapamil\n Nausea/Vomiting\n Beta-Adrenergic Agents\n bradycardia;\n Captopril\n elevated potass\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n - Lanthanum 250 mg PO BID\n - Psyllium 1.7 g Wafer PO BID\n - Calcitonin 200 unit/Actuation Aerosol Nasal DAILY\n - Captopril 37.5 mg PO TID\n - Insulin Glargine 14 SQ DAILY plus HISS\n - Aspirin 81 mg PO DAILY\n - Heparin 5,000 units SQ \n - Methimazole 10 mg PO DAILY\n - Simvastatin 20 mg PO QHS\n - Cipro 750 mg PO DAILY, give after HD on HD days for 6 weeks\n - Flagyl 500 mg PO TID for 6 weeks\n - Labetalol 200 mg PO BID (taking as TID)\n - Ascorbic Acid 500 mg PO BID for 10 days ( to 19/09)\n - Vitamin A 20,000 units PO DAILY\n - Polyvinyl Alcohol-Povidone 1.4-0.6% Ophthalmic PRN: eye pain\n - B Complex-Vitamin C-Folic Acid PO DAILY\n - Vancomycin 1,000 IV QHD protocol for 6 weeks\n Past medical history:\n Family history:\n Social History:\n - Multiple admissions for toxic metabolic encephalopathy- extensively\n worked up with MRI, EEG, and neurologic consultations. These episodes\n are typically secondary to infections, missed dialysis sessions or\n other metabolic derrangements, and are quite profound clinically.\n - Type 2 Diabetes with labile blood surgars\n - Coronary artery disease\n - Peripheral vascular disease\n - Hypertension\n - Pulmonary hypertension\n - h/o subdural hematoma and intracranial hemorrhage in and\n neurosurgery in \n - Toxic Multinodular Goiter\n - Chronic kidney disease on HD (Tues/ Thurs/ Sat)\n - Lumbar disc disease\n - Osteoarthritis\n - Anemia - low iron and EPO\n - s/p Breast biopsy\n - s/p Hysterectomy\n - s/p transmetatarsal amputation (right foot)\n - Saccral decubitus with possible osteomyelitis. On 6 week course of\n vanco/cipro/flagyl starting on \n - Diabetes (sister)\n - Cancer in brothers and father (leukemia, prostate)\n Occupation:\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: - Has been in and out of various longterm care facilities and\n rehabs since admission in . Prior to patient was ambulatory\n with walker and could feed herself; but has not been ambulatory since\n that time. As of living at home with VNA. At baseline, she is not\n confused (as per sister) but in normally barely verbal.\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denies\n cough, shortness of breath, or wheezing. Denies chest pain, chest\n pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea,\n constipation, abdominal pain, or changes in bowel habits. Denies\n dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies\n rashes or skin changes.\n Flowsheet Data as of 10:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 68 (68 - 79) bpm\n BP: 69/31(41) {69/31(41) - 109/52(66)} mmHg\n RR: 19 (19 - 25) insp/min\n SpO2: 100%\n CVP: 3 (3 - 5)mmHg\n Total In:\n 900 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 900 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [1] 01:50PM\n 10.9\n 3.86*\n 9.6*\n 33.4*\n 87\n 25.0*\n 28.8*\n 19.8*\n 328\n [2] 12:00PM\n 14.4*#\n 4.21\n 10.3*\n 37.5\n 89\n 24.4*\n 27.4*\n 19.8*\n 325\n [3] 05:40AM\n 6.9\n 3.67*\n 9.1*\n 31.9*\n 87\n 24.8*\n 28.6*\n 18.7*\n 293\n RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [4] 01:50PM\n 45*[1]\n 49*\n 3.9*#\n 149*\n 3.6\n 105\n 34*\n 14\n [5] 05:40AM\n 87\n 17\n 2.8*#\n 144\n 3.7\n 103\n 33*\n 12\n ENZYMES & BILIRUBIN\n ALT\n AST\n LD(LDH)\n CK(CPK)\n AlkPhos\n Amylase\n TotBili\n DirBili\n [6] 12:00PM\n 37\n 51*\n 145*\n 0.5\n [7][image001.gif] CHEMISTRY\n TotProt\n Albumin\n Globuln\n Calcium\n Phos\n Mg\n UricAcd\n Iron\n [8] 01:50PM\n 10.7*\n 3.2\n 2.1\n [9] 05:40AM\n 10.1\n 3.1\n 2.0\n Images:\n CT HEAD W/O CONTRAST Study Date of 12:48 PM Preliminary Report\n !! WET READ !! New hypodensity RIGHT temporo-parietal region\n concerning for an acute infarct ? watershed.\n .\n CT TORSE W/CONTRAST Study Date of 12:16 PM Preliminary Report\n !! WET READ !! Sacral ulcer extends to bone with probable signs of\n osteomyelitis. 3 x 1 cm fluid collection adj to right greater\n trochanter is new may be inflamatory or traumatic. PUlm nodules f/u in\n 3 months ? 8mm right renal enhancing lesion.\n Assessment and Plan\n 81F with dementia, chronic saccral decubitus ulcer to the bone on long\n term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD,\n PVD, and ESRD on HD admitted from home for altered mental status. CT\n showed likely new CVA. Saccral wound seems similar to past. New\n findings include possible trochanteric bursitis versus abscess,\n possible RCC, and large thyroid mass palpable on exam and visable on\n CT. She had a brief hypotensive event in the ED but is HD stable since.\n She also has been taking extra doses of labetalol at home.\n .\n # Altered mental status: Likely due to new CVA. Seems to have resolved\n to some degree at this point. Also could be due to hypotension from\n extra dose of labetalol. Infection can also cause a neurologicla\n decompensation.\n - Neurology consulting. Recommendations appreciated\n - Continue home simvastatin\n - Increase ASA to 325mg PO daily\n - Infectious workup with BCx and wound Cx\n - Monitor on tele\n - TSH, B12, and folic acid pending\n .\n # Saccral decubitus: Chronic. Per sister is stable to improved.\n - Surgery following. Recommendations appreciated\n - Orthopedics following. Recommendations appreciated\n - Continue wet to dry dressings\n - Have patient in a KinAir bed\n - Broaden cipro / flagyl to pip/tazo 2.25mg IV Q6H\n - Continue vancomycin 1g IV QHD\n - Wound Cx pending\n .\n # Trochanteric collection: Looks like bursitis on CT. No overlying skin\n breakdown or tenderness.\n - Orthopedics following. Recommendations appreciated.\n - IR guided aspiration in the AM\n .\n # New CVA: CT showed new R parietotemoral CVA.\n - Neurology consulting. Recommendations appreciated.\n - Increase ASA to 325mg PO daily\n - Continue simvastatin 20mg PO HS\n - Will obtain MRI MRA of the head and neck once stable\n - Monitor on tele for Afib\n - Will obtain ECHO in the AM\n - Allow BPs to autoregular between 120 to 160 SBP\n .\n # Thyroid mass: Seen on physical exam and CT.\n - Thyroid US and possible Bx pending\n .\n # ESRD: Renal aware Pt admitted.\n - Hold HD until BP stabilized\n - Continue Calcitonin Salmon 200 UNIT NAS DAILY\n - Continue Lanthanum 250 mg PO/NG \n .\n # Diabetes: Continue glargine and HISS\n .\n # FEN: No IVF, replete electrolytes per renal, continue tube feeds\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n # Access: R subclavian, PIV, femoral HD line\n # Communication: \n # Code: Full (discussed with HCP \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 07:17 PM\n Multi Lumen - 07:18 PM\n 18 Gauge - 07:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_1%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n 4. JavaScript:parent.POPUP(self,%22_WEBTAG=_42%22);\n 5. JavaScript:parent.POPUP(self,%22_WEBTAG=_43%22);\n 6. JavaScript:parent.POPUP(self,%22_WEBTAG=_63%22);\n 7. javascript:command('LCBI','expand')\n 8. JavaScript:parent.POPUP(self,%22_WEBTAG=_64%22);\n 9. JavaScript:parent.POPUP(self,%22_WEBTAG=_65%22);\n" }, { "category": "Physician ", "chartdate": "2115-01-06 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 507186, "text": "TITLE:\n Chief Complaint: altered mental status\n HPI:\n 81F with dementia, chronic saccral decubitus ulcer to the bone on long\n term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD,\n PVD, and ESRD on HD admitted from home for altered mental status. She\n is barely verbal but responsive at baseline, but became transiently\n unresponsive the morning of admission when transport came to take her\n to HD. She was taken to the ED at where her initial vital signs were\n 98.0 94/60 66 15 96% on RA. A stat CT head showed a new parietotemporal\n hypodensity consistent with acute CVA. Neurology was consulted. She\n then became hypotensive to 68/50. She was bolused 1L NS, given pip-tazo\n and cipro for double coverage of Pseudomonas. She was not given an\n additional dose of vancomycin or other Gram positive coverage. A\n subclavian line was placed and she was sent for a torso CT to eval for\n sites of infection. The CT showed her known saccral decubitus ulcer\n tracking to the bone, a new fluid collection over the R greater\n trochanter, and a newly notes renal lesion concerning for RCC. Her BP\n stabilized after fluid bolus and she was never on pressors. General\n surgery and orthopedic surgery were consulted regarding her saccral and\n trochanteric processes and she was admitted to the MICU service.\n .\n On the floor she is A and O x 2 to person and place, and barely verbal.\n Per her sister who was at the bedside, she is at her baseline at this\n point. She denies pain, fevers, chills, or sweats. Her she is somewhat\n dysarthric but is normally so.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy, dementia\n Allergies:\n Lisinopril\n hyperkalemia at\n Verapamil\n Nausea/Vomiting\n Beta-Adrenergic Agents\n bradycardia;\n Captopril\n elevated potass\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n - Lanthanum 250 mg PO BID\n - Psyllium 1.7 g Wafer PO BID\n - Calcitonin 200 unit/Actuation Aerosol Nasal DAILY\n - Captopril 37.5 mg PO TID\n - Insulin Glargine 14 SQ DAILY plus HISS\n - Aspirin 81 mg PO DAILY\n - Heparin 5,000 units SQ \n - Methimazole 10 mg PO DAILY\n - Simvastatin 20 mg PO QHS\n - Cipro 750 mg PO DAILY, give after HD on HD days for 6 weeks\n - Flagyl 500 mg PO TID for 6 weeks\n - Labetalol 200 mg PO BID (taking as TID)\n - Ascorbic Acid 500 mg PO BID for 10 days ( to 19/09)\n - Vitamin A 20,000 units PO DAILY\n - Polyvinyl Alcohol-Povidone 1.4-0.6% Ophthalmic PRN: eye pain\n - B Complex-Vitamin C-Folic Acid PO DAILY\n - Vancomycin 1,000 IV QHD protocol for 6 weeks\n Past medical history:\n Family history:\n Social History:\n - Multiple admissions for toxic metabolic encephalopathy- extensively\n worked up with MRI, EEG, and neurologic consultations. These episodes\n are typically secondary to infections, missed dialysis sessions or\n other metabolic derrangements, and are quite profound clinically.\n - Type 2 Diabetes with labile blood surgars\n - Coronary artery disease\n - Peripheral vascular disease\n - Hypertension\n - Pulmonary hypertension\n - h/o subdural hematoma and intracranial hemorrhage in and\n neurosurgery in \n - Toxic Multinodular Goiter\n - Chronic kidney disease on HD (Tues/ Thurs/ Sat)\n - Lumbar disc disease\n - Osteoarthritis\n - Anemia - low iron and EPO\n - s/p Breast biopsy\n - s/p Hysterectomy\n - s/p transmetatarsal amputation (right foot)\n - Saccral decubitus with possible osteomyelitis. On 6 week course of\n vanco/cipro/flagyl starting on \n - Diabetes (sister)\n - Cancer in brothers and father (leukemia, prostate)\n Occupation:\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: - Has been in and out of various longterm care facilities and\n rehabs since admission in . Prior to patient was ambulatory\n with walker and could feed herself; but has not been ambulatory since\n that time. As of living at home with VNA. At baseline, she is not\n confused (as per sister) but in normally barely verbal.\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denies\n cough, shortness of breath, or wheezing. Denies chest pain, chest\n pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea,\n constipation, abdominal pain, or changes in bowel habits. Denies\n dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies\n rashes or skin changes.\n Flowsheet Data as of 10:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 68 (68 - 79) bpm\n BP: 69/31(41) {69/31(41) - 109/52(66)} mmHg\n RR: 19 (19 - 25) insp/min\n SpO2: 100%\n CVP: 3 (3 - 5)mmHg\n Total In:\n 900 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 900 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n GEN: Ill appearing elderly woman in NAD\n HEENT: MMM, no OP lesions, dentures in place, face is symmetric, no\n cervical LAD, enlarged thyroid\n CV: RR, III/VI early systolic murmur\n PULM: CTAB no wheezes or rhonchi\n ABD: BS+, NTND, no masses or HSM\n LIMSB: no toes on the R foot, wasted limbs, contractures, resting\n tremors\n SKIN: 5cm saccral decubitus to the bone and tracking under the skin\n NEURO: A and O x 2, pupils symmetric and minimially reactive, reflexes\n 3+ of the RUE and 1+ of LUE and bilat \n / Radiology\n COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [1] 01:50PM\n 10.9\n 3.86*\n 9.6*\n 33.4*\n 87\n 25.0*\n 28.8*\n 19.8*\n 328\n [2] 12:00PM\n 14.4*#\n 4.21\n 10.3*\n 37.5\n 89\n 24.4*\n 27.4*\n 19.8*\n 325\n [3] 05:40AM\n 6.9\n 3.67*\n 9.1*\n 31.9*\n 87\n 24.8*\n 28.6*\n 18.7*\n 293\n RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [4] 01:50PM\n 45*[1]\n 49*\n 3.9*#\n 149*\n 3.6\n 105\n 34*\n 14\n [5] 05:40AM\n 87\n 17\n 2.8*#\n 144\n 3.7\n 103\n 33*\n 12\n ENZYMES & BILIRUBIN\n ALT\n AST\n LD(LDH)\n CK(CPK)\n AlkPhos\n Amylase\n TotBili\n DirBili\n [6] 12:00PM\n 37\n 51*\n 145*\n 0.5\n [7][image001.gif] CHEMISTRY\n TotProt\n Albumin\n Globuln\n Calcium\n Phos\n Mg\n UricAcd\n Iron\n [8] 01:50PM\n 10.7*\n 3.2\n 2.1\n [9] 05:40AM\n 10.1\n 3.1\n 2.0\n Images:\n CT HEAD W/O CONTRAST Study Date of 12:48 PM Preliminary Report\n !! WET READ !! New hypodensity RIGHT temporo-parietal region\n concerning for an acute infarct ? watershed.\n .\n CT TORSE W/CONTRAST Study Date of 12:16 PM Preliminary Report\n !! WET READ !! Sacral ulcer extends to bone with probable signs of\n osteomyelitis. 3 x 1 cm fluid collection adj to right greater\n trochanter is new may be inflamatory or traumatic. PUlm nodules f/u in\n 3 months ? 8mm right renal enhancing lesion.\n Assessment and Plan\n 81F with dementia, chronic saccral decubitus ulcer to the bone on long\n term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD,\n PVD, and ESRD on HD admitted from home for altered mental status. CT\n showed likely new CVA. Saccral wound seems similar to past. New\n findings include possible trochanteric bursitis versus abscess,\n possible RCC, and large thyroid mass palpable on exam and visable on\n CT. She had a brief hypotensive event in the ED but is HD stable since.\n She also has been taking extra doses of labetalol at home.\n .\n # Altered mental status: Likely due to new CVA. Seems to have resolved\n to some degree at this point. Also could be due to hypotension from\n extra dose of labetalol. Infection can also cause a neurologicla\n decompensation.\n - Neurology consulting. Recommendations appreciated\n - Continue home simvastatin\n - Increase ASA to 325mg PO daily\n - Infectious workup with BCx and wound Cx\n - Monitor on tele\n - TSH, B12, and folic acid pending\n .\n # Saccral decubitus: Chronic. Per sister is stable to improved.\n - Surgery following. Recommendations appreciated\n - Orthopedics following. Recommendations appreciated\n - Continue wet to dry dressings\n - Have patient in a KinAir bed\n - Broaden cipro / flagyl to pip/tazo 2.25mg IV Q6H\n - Continue vancomycin 1g IV QHD\n - Wound Cx pending\n .\n # Trochanteric collection: Looks like bursitis on CT. No overlying skin\n breakdown or tenderness.\n - Orthopedics following. Recommendations appreciated.\n - IR guided aspiration in the AM\n .\n # New CVA: CT showed new R parietotemoral CVA.\n - Neurology consulting. Recommendations appreciated.\n - Increase ASA to 325mg PO daily\n - Continue simvastatin 20mg PO HS\n - Will obtain MRI MRA of the head and neck once stable\n - Monitor on tele for Afib\n - Will obtain ECHO in the AM\n - Allow BPs to autoregular between 120 to 160 SBP\n .\n # Thyroid mass: Seen on physical exam and CT.\n - Thyroid US and possible Bx pending\n .\n # ESRD: Renal aware Pt admitted.\n - Hold HD until BP stabilized\n - Continue Calcitonin Salmon 200 UNIT NAS DAILY\n - Continue Lanthanum 250 mg PO/NG \n .\n # Diabetes: Continue glargine and HISS\n .\n # FEN: No IVF, replete electrolytes per renal, continue tube feeds\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n # Access: R subclavian, PIV, femoral HD line\n # Communication: \n # Code: Full (discussed with HCP \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 07:17 PM\n Multi Lumen - 07:18 PM\n 18 Gauge - 07:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_1%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n 4. JavaScript:parent.POPUP(self,%22_WEBTAG=_42%22);\n 5. JavaScript:parent.POPUP(self,%22_WEBTAG=_43%22);\n 6. JavaScript:parent.POPUP(self,%22_WEBTAG=_63%22);\n 7. javascript:command('LCBI','expand')\n 8. JavaScript:parent.POPUP(self,%22_WEBTAG=_64%22);\n 9. JavaScript:parent.POPUP(self,%22_WEBTAG=_65%22);\n" }, { "category": "Physician ", "chartdate": "2115-01-06 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 507187, "text": "TITLE:\n Chief Complaint: altered mental status\n HPI:\n 81F with dementia, chronic saccral decubitus ulcer to the bone on long\n term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD,\n PVD, and ESRD on HD admitted from home for altered mental status. She\n is barely verbal but responsive at baseline, but became transiently\n unresponsive the morning of admission when transport came to take her\n to HD. She was taken to the ED at where her initial vital signs were\n 98.0 94/60 66 15 96% on RA. A stat CT head showed a new parietotemporal\n hypodensity consistent with acute CVA. Neurology was consulted. She\n then became hypotensive to 68/50. She was bolused 1L NS, given pip-tazo\n and cipro for double coverage of Pseudomonas. She was not given an\n additional dose of vancomycin or other Gram positive coverage. A\n subclavian line was placed and she was sent for a torso CT to eval for\n sites of infection. The CT showed her known saccral decubitus ulcer\n tracking to the bone, a new fluid collection over the R greater\n trochanter, and a newly notes renal lesion concerning for RCC. Her BP\n stabilized after fluid bolus and she was never on pressors. General\n surgery and orthopedic surgery were consulted regarding her saccral and\n trochanteric processes and she was admitted to the MICU service.\n .\n On the floor she is A and O x 2 to person and place, and barely verbal.\n Per her sister who was at the bedside, she is at her baseline at this\n point. She denies pain, fevers, chills, or sweats. Her she is somewhat\n dysarthric but is normally so.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy, dementia\n Allergies:\n Lisinopril\n hyperkalemia at\n Verapamil\n Nausea/Vomiting\n Beta-Adrenergic Agents\n bradycardia;\n Captopril\n elevated potass\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n - Lanthanum 250 mg PO BID\n - Psyllium 1.7 g Wafer PO BID\n - Calcitonin 200 unit/Actuation Aerosol Nasal DAILY\n - Captopril 37.5 mg PO TID\n - Insulin Glargine 14 SQ DAILY plus HISS\n - Aspirin 81 mg PO DAILY\n - Heparin 5,000 units SQ \n - Methimazole 10 mg PO DAILY\n - Simvastatin 20 mg PO QHS\n - Cipro 750 mg PO DAILY, give after HD on HD days for 6 weeks\n - Flagyl 500 mg PO TID for 6 weeks\n - Labetalol 200 mg PO BID (taking as TID)\n - Ascorbic Acid 500 mg PO BID for 10 days ( to 19/09)\n - Vitamin A 20,000 units PO DAILY\n - Polyvinyl Alcohol-Povidone 1.4-0.6% Ophthalmic PRN: eye pain\n - B Complex-Vitamin C-Folic Acid PO DAILY\n - Vancomycin 1,000 IV QHD protocol for 6 weeks\n Past medical history:\n Family history:\n Social History:\n - Multiple admissions for toxic metabolic encephalopathy- extensively\n worked up with MRI, EEG, and neurologic consultations. These episodes\n are typically secondary to infections, missed dialysis sessions or\n other metabolic derrangements, and are quite profound clinically.\n - Type 2 Diabetes with labile blood surgars\n - Coronary artery disease\n - Peripheral vascular disease\n - Hypertension\n - Pulmonary hypertension\n - h/o subdural hematoma and intracranial hemorrhage in and\n neurosurgery in \n - Toxic Multinodular Goiter\n - Chronic kidney disease on HD (Tues/ Thurs/ Sat)\n - Lumbar disc disease\n - Osteoarthritis\n - Anemia - low iron and EPO\n - s/p Breast biopsy\n - s/p Hysterectomy\n - s/p transmetatarsal amputation (right foot)\n - Saccral decubitus with possible osteomyelitis. On 6 week course of\n vanco/cipro/flagyl starting on \n - Diabetes (sister)\n - Cancer in brothers and father (leukemia, prostate)\n Occupation:\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: - Has been in and out of various longterm care facilities and\n rehabs since admission in . Prior to patient was ambulatory\n with walker and could feed herself; but has not been ambulatory since\n that time. As of living at home with VNA. At baseline, she is not\n confused (as per sister) but in normally barely verbal.\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denies\n cough, shortness of breath, or wheezing. Denies chest pain, chest\n pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea,\n constipation, abdominal pain, or changes in bowel habits. Denies\n dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies\n rashes or skin changes.\n Flowsheet Data as of 10:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 68 (68 - 79) bpm\n BP: 69/31(41) {69/31(41) - 109/52(66)} mmHg\n RR: 19 (19 - 25) insp/min\n SpO2: 100%\n CVP: 3 (3 - 5)mmHg\n Total In:\n 900 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 900 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n GEN: Ill appearing elderly woman in NAD\n HEENT: MMM, no OP lesions, dentures in place, face is symmetric, no\n cervical LAD, enlarged thyroid\n CV: RR, III/VI early systolic murmur\n PULM: CTAB no wheezes or rhonchi\n ABD: BS+, NTND, no masses or HSM\n LIMSB: no toes on the R foot, wasted limbs, contractures, resting\n tremors\n SKIN: 5cm saccral decubitus to the bone and tracking under the skin\n NEURO: A and O x 2, pupils symmetric and minimially reactive, reflexes\n 3+ of the RUE and 1+ of LUE and bilat \n / Radiology\n COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [1] 01:50PM\n 10.9\n 3.86*\n 9.6*\n 33.4*\n 87\n 25.0*\n 28.8*\n 19.8*\n 328\n [2] 12:00PM\n 14.4*#\n 4.21\n 10.3*\n 37.5\n 89\n 24.4*\n 27.4*\n 19.8*\n 325\n [3] 05:40AM\n 6.9\n 3.67*\n 9.1*\n 31.9*\n 87\n 24.8*\n 28.6*\n 18.7*\n 293\n RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [4] 01:50PM\n 45*[1]\n 49*\n 3.9*#\n 149*\n 3.6\n 105\n 34*\n 14\n [5] 05:40AM\n 87\n 17\n 2.8*#\n 144\n 3.7\n 103\n 33*\n 12\n ENZYMES & BILIRUBIN\n ALT\n AST\n LD(LDH)\n CK(CPK)\n AlkPhos\n Amylase\n TotBili\n DirBili\n [6] 12:00PM\n 37\n 51*\n 145*\n 0.5\n [7][image001.gif] CHEMISTRY\n TotProt\n Albumin\n Globuln\n Calcium\n Phos\n Mg\n UricAcd\n Iron\n [8] 01:50PM\n 10.7*\n 3.2\n 2.1\n [9] 05:40AM\n 10.1\n 3.1\n 2.0\n Images:\n CT HEAD W/O CONTRAST Study Date of 12:48 PM Preliminary Report\n !! WET READ !! New hypodensity RIGHT temporo-parietal region\n concerning for an acute infarct ? watershed.\n .\n CT TORSE W/CONTRAST Study Date of 12:16 PM Preliminary Report\n !! WET READ !! Sacral ulcer extends to bone with probable signs of\n osteomyelitis. 3 x 1 cm fluid collection adj to right greater\n trochanter is new may be inflamatory or traumatic. PUlm nodules f/u in\n 3 months ? 8mm right renal enhancing lesion.\n Assessment and Plan\n 81F with dementia, chronic saccral decubitus ulcer to the bone on long\n term antibiotics, s/p SDH, DM-II with labile blood sugars, HTN, CAD,\n PVD, and ESRD on HD admitted from home for altered mental status. CT\n showed likely new CVA. Saccral wound seems similar to past. New\n findings include possible trochanteric bursitis versus abscess,\n possible RCC, and large thyroid mass palpable on exam and visable on\n CT. She had a brief hypotensive event in the ED but is HD stable since.\n She also has been taking extra doses of labetalol at home.\n .\n # Altered mental status: Likely due to new CVA. Seems to have resolved\n to some degree at this point. Also could be due to hypotension from\n extra dose of labetalol. Infection can also cause a neurologicla\n decompensation.\n - Neurology consulting. Recommendations appreciated\n - Continue home simvastatin\n - Increase ASA to 325mg PO daily\n - Infectious workup with BCx and wound Cx\n - Monitor on tele\n - TSH, B12, and folic acid pending\n .\n # Saccral decubitus: Chronic. Per sister is stable to improved.\n - Surgery following. Recommendations appreciated\n - Orthopedics following. Recommendations appreciated\n - Continue wet to dry dressings\n - Have patient in a KinAir bed\n - Broaden cipro / flagyl to pip/tazo 2.25mg IV Q6H\n - Continue vancomycin 1g IV QHD\n - Wound Cx pending\n .\n # Trochanteric collection: Looks like bursitis on CT. No overlying skin\n breakdown or tenderness.\n - Orthopedics following. Recommendations appreciated.\n - IR guided aspiration in the AM\n .\n # New CVA: CT showed new R parietotemoral CVA.\n - Neurology consulting. Recommendations appreciated.\n - Increase ASA to 325mg PO daily\n - Continue simvastatin 20mg PO HS\n - Will obtain MRI MRA of the head and neck once stable\n - Monitor on tele for Afib\n - Will obtain ECHO in the AM\n - Allow BPs to autoregular between 120 to 160 SBP\n .\n # Thyroid mass: Seen on physical exam and CT.\n - Thyroid US and possible Bx pending\n .\n # ESRD: Renal aware Pt admitted.\n - Hold HD until BP stabilized\n - Continue Calcitonin Salmon 200 UNIT NAS DAILY\n - Continue Lanthanum 250 mg PO/NG \n .\n # Diabetes: Continue glargine and HISS\n .\n # FEN: No IVF, replete electrolytes per renal, continue tube feeds\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n # Access: R subclavian, PIV, femoral HD line\n # Communication: \n # Code: Full (discussed with HCP \n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 07:17 PM\n Multi Lumen - 07:18 PM\n 18 Gauge - 07:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_1%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n 4. JavaScript:parent.POPUP(self,%22_WEBTAG=_42%22);\n 5. JavaScript:parent.POPUP(self,%22_WEBTAG=_43%22);\n 6. JavaScript:parent.POPUP(self,%22_WEBTAG=_63%22);\n 7. javascript:command('LCBI','expand')\n 8. JavaScript:parent.POPUP(self,%22_WEBTAG=_64%22);\n 9. JavaScript:parent.POPUP(self,%22_WEBTAG=_65%22);\n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507234, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt with dementia, labile blood sugars. CT showed likely new R\n parietemoral CVA. Pt was able to speak with one word responses oriented\n x3 at beginning of night pt became more lethargic and by midnight pt\n was very difficult to arouse pt was unable to answer questions at 0300\n pt awoke spontaneously and was able to speak clearly two word but pt\n was not oriented x3 s\n Action:\n Pt aroused q hour assessing mental status\n Response:\n Pt very lethargic too difficult to stay awake to answer questions\n Plan:\n Continue to assess mental status , infectious workup\n Hypotension (not Shock)\n Assessment:\n Pt is a hemodialysis pt x days a week pt usually has high bp sys 160\n Bp low sys 90\ns-100\ns now.\n Action:\n Antibiotics and 500cc NS bolus\n Response:\n Pt responded well to bolusu increased bp\n Plan:\n Continue to assess bp hr rhythm, obtain cultures assess temp monitor\n for signs of sepsis\n Impaired Skin Integrity\n Assessment:\n Chronic sacral decubitus ulcer to the bone on long term antibiotcs\n Action:\n MD in to assess removed dressing ulcer clean healing MD\ns, changed\n to KINAIR bed\n Response:\n dressing changes wet to dry\n Plan:\n Assess for pain change position frequently, cultures pending\n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507193, "text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507299, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt with dementia, labile blood sugars. CT showed likely new R\n parietemoral CVA. Pt was able to speak with one word responses oriented\n x3 at beginning of night pt became more lethargic and by midnight pt\n was very difficult to arouse pt was unable to answer questions at 0300\n pt awoke spontaneously and was able to speak clearly two word but pt\n was not oriented x3\n Action:\n Pt aroused q hour assessing mental status\n Response:\n Pt very lethargic too difficult to stay awake to answer questions\n Plan:\n Continue to assess mental status , infectious workup\n Hypotension (not Shock)\n Assessment:\n Pt is a hemodialysis pt x days a week pt usually has high bp sys 160\n Bp low sys 90\ns-100\ns now.\n Action:\n Antibiotics and 500cc NS bolus\n Response:\n Pt responded well to bolusu increased bp\n Plan:\n Continue to assess bp hr rhythm, obtain cultures assess temp monitor\n for signs of sepsis\n Impaired Skin Integrity\n Assessment:\n Chronic sacral decubitus ulcer to the bone on long term antibiotics\n Action:\n MD in to assess removed dressing ulcer clean healing MD\ns, changed\n to KINAIR bed\n Response:\n dressing changes wet to dry\n Plan:\n Assess for pain change position frequently, cultures pending\n" }, { "category": "Nursing", "chartdate": "2115-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 507300, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt with dementia, labile blood sugars. CT showed likely new R\n parietemoral CVA. Pt was able to speak with one word responses oriented\n x3 at beginning of night pt became more lethargic and by midnight pt\n was very difficult to arouse pt was unable to answer questions at 0300\n pt awoke spontaneously and was able to speak clearly two word but pt\n was not oriented x3\n Action:\n Pt aroused q hour assessing mental status\n Response:\n Pt very lethargic too difficult to stay awake to answer questions\n Plan:\n Continue to assess mental status , infectious workup\n Hypotension (not Shock)\n Assessment:\n Pt is a hemodialysis pt x days a week pt usually has high bp sys 160\n Bp low sys 90\ns-100\ns now.\n Action:\n Antibiotics and 500cc NS bolus\n Response:\n Pt responded well to bolusu increased bp\n Plan:\n Continue to assess bp hr rhythm, obtain cultures assess temp monitor\n for signs of sepsis\n Impaired Skin Integrity\n Assessment:\n Chronic sacral decubitus ulcer to the bone on long term antibiotics\n Action:\n MD in to assess removed dressing ulcer clean healing MD\ns, changed\n to KINAIR bed\n Response:\n dressing changes wet to dry\n Plan:\n Assess for pain change position frequently, cultures pending\n" }, { "category": "ECG", "chartdate": "2115-01-06 00:00:00.000", "description": "Report", "row_id": 275386, "text": "Sinus rhythm. Occasional atrial premature beats. Compared to tracing #2\natrial premature beats are new. Otherwise, no other significant diagnostic\nchange.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2115-01-05 00:00:00.000", "description": "Report", "row_id": 275387, "text": "Sinus rhythm. Right bundle-branch block. Compared to tracing #1 there is no\nsignificant diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2115-01-05 00:00:00.000", "description": "Report", "row_id": 275388, "text": "Sinus rhythm. Right bundle-branch block. Compared to the previous tracing\nof there is no significant diagnostic change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2179-02-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435656, "text": " pedestrian struck, upon arrival to ED, BS 35 with no recall of\n accident. +ETOH. Injuries: right humeral neck fx, right femoral greater\n trochanteric fx's, right superior and inferior pubic rami fx's, right\n sacral fx, L2-L3 left transverse process fx. Pt was tx to CC6. Admitted\n to TSICU due to change in mental status. Pt displaying auditory\n and visual hulluciantions with aggitation. CIWA scale ordered.\n Delirium / confusion\n Assessment:\n Pt oriented to self only. Not aware of place or time. Mae\ns. Painful\n lower ext\ns from ? neuropathy. Odd affect, at times wont respond to\n questions asked. Garbled / slurred speech, difficult to understand.\n Pupils 2mm brisk. Ciwa scale. ? concussive inj, ? etoh w/drawal. Hx of\n lg etoh use\n Action:\n Suggested CT of head. pt as needed, maintain safety, bed\n alarm on. Ativan as needed.\n Response:\n No changes, no Ct suggested by covering resident.\n Plan:\n Cont to closely monitor, medicate as needed.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Hct drop to 19\n Action:\n Transfuse 2 units of red cells.\n Response:\n Vss, Bp stable except diastolic elevated (MD aware)\n Plan:\n Repeat hct, transfuse as needed.\n Hypoglycemia\n Assessment:\n Pt diabetic, per report of floor hypoglycemic events.\n Action:\n Bld sugars q2 hrs.\n Response:\n Stable 70-190\ns, insulin as needed\n Plan:\n Cont to closely monitor\n" }, { "category": "Nursing", "chartdate": "2179-02-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 435827, "text": "Delirium / confusion\n Assessment:\n A&Ox1-2 (person, sometimes\nhospital\n). Converses semi-appropriately\n about his injuries and need for surgery. CIWA maintained <10 with\n standing ativan 1mg IV q4. MAE with normal strength relative to\n injuries. PERRL 2mm. Gag, cough intact.\n Action:\n CIWA scale. Ativan 1mg IV q4 with PRN for CIWA>10\n Response:\n No additional ativan needed this shift, remains safe.\n Plan:\n Continue CIWA, orientation.\n Fracture, other\n Assessment:\n Noted swelling, redness, painful left ankle.\n Action:\n Xrays ordered.\n Response:\n Comminuted proximal fibular fracture and comminuted spiral distal\n fibula fractures identified.\n Plan:\n OR tomorrow with orthopedics for left distal tibia and right arm.\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435930, "text": "Delirium / confusion\n Assessment:\n Disoriented, confused, combative since last night, trying to pull lines\n out\n Action:\n Ativan +PRN SIWA scale, restrained, trying to reorient patient\n Response:\n Slept most of the night with Dilodid/ativan administration\n Plan:\n Reorient patient, manage DTs with ativan, adequate pain management\n Fracture, other\n Assessment:\n Bilateral femur fx, r. shoulder fx, L foot fx\n Action:\n Repositioning often, pain control, elevation of extremities\n Response:\n Pt slept on and off, no additional deformities of swelling noted\n Plan:\n OR today with ortho for L. foot reduction\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435931, "text": "Delirium / confusion\n Assessment:\n Disoriented, confused, combative since last night, trying to pull lines\n out\n Action:\n Ativan +PRN SIWA scale, restrained, trying to reorient patient\n Response:\n Slept most of the night with Dilodid/ativan administration\n Plan:\n Reorient patient, manage DTs with ativan, adequate pain management\n Fracture, other\n Assessment:\n Bilateral femur fx, r. shoulder fx, L foot fx\n Action:\n Repositioning often, pain control, elevation of extremities\n Response:\n Pt slept on and off, no additional deformities of swelling noted\n Plan:\n OR today with ortho for L. foot reduction\n Problem\n alteration in skin integrity\n Assessment:\n Multiple abrasions and bruises. L. heel pressure ulcer stage I was\n identified last night\n Action:\n Multipodis boot on the L. heel, repositioning\n Response:\n Same injuries remain, same severity\n Plan:\n Skin care, repositioning\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436032, "text": "HPI: 48 yr old male who initially slipped on ice while walking one week\n prior to getting struck by car. He had gone to an OSH and had sustained\n a right humerus and the abrasions on his knuckles. He later been\n discharged and sent home with a scheduled date to come back and have a\n scheduled ORIF.\n Unsure of how many days later per reports of family it happened to be\n the following day pt was walking down his street and was struck by a\n car. Unknown speed. + ETOH +LOC, found unresponsive with FS 20-30,\n given 1 Amp D50 and transferred to on for further\n management. Pt was then sent to cc6 from ED on \n Injuries include: Rt humeral neck fx, left distal tib/fib fx, right\n femoral greater trochanteric fx's, right superior and inferior pubic\n rami fx's, right sacral fx, L2-L3 left transverse process fx. Found to\n have multiple fractures but ortho surgery deferred due to elevated INR\n of 1.5.\n Pt triggered on floor for low blood sugars, change in mental status,\n also hct fell from 26.9 on admission to 19 today, unclear source of\n bleeding as CT torso did not show hematoma. Transferred to TSICU for\n monitoring. Pt stable in Tsicu, consulted. Plan for Or today,\n but per request of trauma pt get and IVC filter prior to surgery.\n Filter placed today through left groin, due to extensive time in angio\n attending unable to perform surgery today, pt is on the list for\n tomorrow a.m.\n .\n Fracture, other\n Assessment:\n Pt with rt humerus fx and left tib/fib fx. Per request pt needs a IVC\n filter prior to OR. Plans for pt to go to OR today for ORIF\n Action:\n Ivc filter 1130-1330 in angio, OR cancelled due to extensive time in\n angio. Left groin drsg, pulse checks, flat till 1730\n Response:\n No changes, extremities warm, palp pulses.\n Plan:\n Cont to monitor, plan for OR in a.m. Splint to left leg and sling on\n Delirium / confusion\n Assessment:\n Pt\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436033, "text": "HPI: 48 yr old male who initially slipped on ice while walking one week\n prior to getting struck by car. He had gone to an OSH and had sustained\n a right humerus and the abrasions on his knuckles. He later been\n discharged and sent home with a scheduled date to come back and have a\n scheduled ORIF.\n Unsure of how many days later per reports of family it happened to be\n the following day pt was walking down his street and was struck by a\n car. Unknown speed. + ETOH +LOC, found unresponsive with FS 20-30,\n given 1 Amp D50 and transferred to on for further\n management. Pt was then sent to cc6 from ED on \n Injuries include: Rt humeral neck fx, left distal tib/fib fx, right\n femoral greater trochanteric fx's, right superior and inferior pubic\n rami fx's, right sacral fx, L2-L3 left transverse process fx. Found to\n have multiple fractures but ortho surgery deferred due to elevated INR\n of 1.5.\n Pt triggered on floor for low blood sugars, change in mental status,\n also hct fell from 26.9 on admission to 19 today, unclear source of\n bleeding as CT torso did not show hematoma. Transferred to TSICU for\n monitoring. Pt stable in Tsicu, consulted. Plan for Or today,\n but per request of trauma pt get and IVC filter prior to surgery.\n Filter placed today through left groin, due to extensive time in angio\n attending unable to perform surgery today, pt is on the list for\n tomorrow a.m.\n Pmh-Diabetes/Htn/Etoh abuse/? Hep C/ Hiv. Pt stated at one point to RN\n pt had diagnoses then denied.\n .\n Fracture, other\n Assessment:\n Pt with rt humerus fx and left tib/fib fx that need fixing in OR. Pt\n with few other ortho fx\ns which will not require surgery. Per request\n pt needs a IVC filter prior to OR. Plans for pt to go to OR today for\n ORIF\n Action:\n Ivc filter 1130-1330 in angio, OR cancelled due to extensive time in\n angio. Left groin drsg, pulse checks, flat till 1730\n Response:\n No changes, extremities warm, palp pulses.\n Plan:\n Cont to monitor, plan for OR in a.m. Splint to left leg and sling on\n Delirium / confusion\n Assessment:\n Pt with extensive hx of ETOH. Confused, agitated, much improved over\n last couple of days.\n Action:\n Ciwa scale as ordered/ Ativan/ Left arm in restraint due to pulling at\n tubes.\n Response:\n Pt\ns mental status improved, oriented to self , hosp and at times yr.\n Remains restrained currently\n Plan:\n Cont to closely monitor, ciwa scale as ordered\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436035, "text": "HPI: 48 yr old male who initially slipped on ice while walking one week\n prior to getting struck by car. He had gone to an OSH and had sustained\n a right humerus and the abrasions on his knuckles. He later been\n discharged and sent home with a scheduled date to come back and have a\n scheduled ORIF.\n Unsure of how many days later per reports of family it happened to be\n the following day pt was walking down his street and was struck by a\n car. Unknown speed. + ETOH +LOC, found unresponsive with FS 20-30,\n given 1 Amp D50 and transferred to on for further\n management. Pt was then sent to cc6 from ED on \n Injuries include: Rt humeral neck fx, left distal tib/fib fx, right\n femoral greater trochanteric fx's, right superior and inferior pubic\n rami fx's, right sacral fx, L2-L3 left transverse process fx. Found to\n have multiple fractures but ortho surgery deferred due to elevated INR\n of 1.5.\n Pt triggered on floor for low blood sugars, change in mental status,\n also hct fell from 26.9 on admission to 19 today, unclear source of\n bleeding as CT torso did not show hematoma. Transferred to TSICU for\n monitoring. Pt stable in Tsicu, consulted. Plan for Or today,\n but per request of trauma pt get and IVC filter prior to surgery.\n Filter placed today through left groin, due to extensive time in angio\n attending unable to perform surgery today, pt is on the list for\n tomorrow a.m.\n Pmh-Diabetes/Htn/Etoh abuse/? Hep C/ Hiv. Pt stated at one point to RN\n pt had diagnoses then denied.\n .\n Fracture, other\n Assessment:\n Pt with rt humerus fx and left tib/fib fx that need fixing in OR. Pt\n with few other ortho fx\ns which will not require surgery. Per request\n pt needs a IVC filter prior to OR. Plans for pt to go to OR today for\n ORIF\n Action:\n Ivc filter 1130-1330 in angio, OR cancelled due to extensive time in\n angio. Left groin drsg, pulse checks, flat till 1730\n Response:\n No changes, extremities warm, palp pulses.\n Plan:\n Cont to monitor, plan for OR in a.m. Splint to left leg and sling on\n Delirium / confusion\n Assessment:\n Pt with extensive hx of ETOH. Confused, agitated, much improved over\n last couple of days.\n Action:\n Ciwa scale as ordered/ Ativan/ Left arm in restraint due to pulling at\n tubes. Re-oriented and bed alarm for fall risk. Pt does not need a\n sitter currently.\n Response:\n Pt\ns mental status improved, oriented to self , hosp and at times yr.\n Remains restrained currently\n Plan:\n Cont to closely monitor, ciwa scale as ordered\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435946, "text": "Delirium / confusion\n Assessment:\n Disoriented, confused, combative since last night, trying to pull lines\n out\n Action:\n Ativan +PRN SIWA scale, restrained, trying to reorient patient\n Response:\n Slept most of the night with Dilodid/ativan administration\n Plan:\n Reorient patient, manage DTs with ativan, adequate pain management\n Fracture, other\n Assessment:\n Bilateral femur fx, r. shoulder fx, L foot fx\n Action:\n Repositioning often, pain control, elevation of extremities\n Response:\n Pt slept on and off, no additional deformities of swelling noted\n Plan:\n OR today with ortho for L. foot reduction\n Problem\n alteration in skin integrity\n Assessment:\n Multiple abrasions and bruises. L. heel pressure ulcer stage I was\n identified last night\n Action:\n Multipodis boot on the L. heel, repositioning\n Response:\n Same injuries remain, same severity\n Plan:\n Skin care, repositioning\n Needs angio +IVC filter before OR\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436065, "text": "HPI: 48 yr old male who initially slipped on ice while walking one week\n prior to getting struck by car. He had gone to an OSH and had sustained\n a right humerus and the abrasions on his knuckles. He later been\n discharged and sent home with a scheduled date to come back and have a\n scheduled ORIF.\n Unsure of how many days later per reports of family it happened to be\n the following day pt was walking down his street and was struck by a\n car. Unknown speed. + ETOH +LOC, found unresponsive with FS 20-30,\n given 1 Amp D50 and transferred to on for further\n management. Pt was then sent to cc6 from ED on \n Injuries include: Rt humeral neck fx, left distal tib/fib fx, right\n femoral greater trochanteric fx's, right superior and inferior pubic\n rami fx's, right sacral fx, L2-L3 left transverse process fx. Found to\n have multiple fractures but ortho surgery deferred due to elevated INR\n of 1.5.\n Pt triggered on floor for low blood sugars, change in mental status,\n also hct fell from 26.9 on admission to 19 , unclear source of bleeding\n as CT torso did not show hematoma. Transferred to TSICU for\n monitoring. Pt stable in Tsicu, consulted. Plan for Or today,\n but per request of trauma pt get and IVC filter prior to surgery.\n Filter placed today through left groin, due to extensive time in angio\n attending unable to perform surgery today, pt is on the list for\n tomorrow a.m.\n Pmh-Diabetes/Htn/Etoh abuse/? Hep C/ Hiv. Pt stated at one point to RN\n pt had diagnoses then denied.\n Pt cleared to go out to floor, report given to RN CC6\n .\n Fracture, other\n Assessment:\n Pt with rt humerus fx and left tib/fib fx that need fixing in OR. Pt\n with few other ortho fx\ns which will not require surgery. Per request\n pt needs a IVC filter prior to OR. Plans for pt to go to OR today for\n ORIF\n Action:\n Ivc filter 1130-1330 in angio, OR cancelled due to extensive time in\n angio. Left groin drsg, pulse checks, flat till 1730\n Response:\n No changes, extremities warm, palp pulses.\n Plan:\n Cont to monitor, plan for OR in a.m. Splint to left leg and sling on\n Delirium / confusion\n Assessment:\n Pt with extensive hx of ETOH. Confused, agitated, much improved over\n last couple of days.\n Action:\n Ciwa scale as ordered/ Ativan/ Left arm in restraint due to pulling at\n tubes. Re-oriented and bed alarm for fall risk. Pt does not need a\n sitter currently.\n Response:\n Pt\ns mental status improved, oriented to self , hosp and at times yr.\n Remains restrained currently\n Plan:\n Cont to closely monitor, ciwa scale as ordered\n Impaired Skin Integrity\n Assessment:\n Pt has stage 2 to right heel.\n Action:\n Foot in multipodis boot, barrier cream.\n Response:\n No changes\n Plan:\n Cont to closely monitor, follow skin closely.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n MOTOR VEHICLE ACCIDENT\n Code status:\n Height:\n Admission weight:\n 56 kg\n Daily weight:\n 55.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Insulin, ETOH\n CV-PMH:\n Additional history: Pt verbalized to RN that he was hep c/HIV positive\n then denied comment later in evening. ? true diagnosis\n Surgery / Procedure and date: Plan today for ORIF of humerus but\n cancelled due to mental status changes\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:160\n D:99\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 92 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,877 mL\n 24h total out:\n 1,285 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 02:26 AM\n Potassium:\n 3.8 mEq/L\n 02:26 AM\n Chloride:\n 100 mEq/L\n 02:26 AM\n CO2:\n 25 mEq/L\n 02:26 AM\n BUN:\n 10 mg/dL\n 02:26 AM\n Creatinine:\n 0.5 mg/dL\n 02:26 AM\n Glucose:\n 143 mg/dL\n 02:26 AM\n Hematocrit:\n 30.8 %\n 02:26 AM\n Finger Stick Glucose:\n 119\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: mother\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: CC6\n Date & time of Transfer: 1830 to RN\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436045, "text": "HPI: 48 yr old male who initially slipped on ice while walking one week\n prior to getting struck by car. He had gone to an OSH and had sustained\n a right humerus and the abrasions on his knuckles. He later been\n discharged and sent home with a scheduled date to come back and have a\n scheduled ORIF.\n Unsure of how many days later per reports of family it happened to be\n the following day pt was walking down his street and was struck by a\n car. Unknown speed. + ETOH +LOC, found unresponsive with FS 20-30,\n given 1 Amp D50 and transferred to on for further\n management. Pt was then sent to cc6 from ED on \n Injuries include: Rt humeral neck fx, left distal tib/fib fx, right\n femoral greater trochanteric fx's, right superior and inferior pubic\n rami fx's, right sacral fx, L2-L3 left transverse process fx. Found to\n have multiple fractures but ortho surgery deferred due to elevated INR\n of 1.5.\n Pt triggered on floor for low blood sugars, change in mental status,\n also hct fell from 26.9 on admission to 19 , unclear source of bleeding\n as CT torso did not show hematoma. Transferred to TSICU for\n monitoring. Pt stable in Tsicu, consulted. Plan for Or today,\n but per request of trauma pt get and IVC filter prior to surgery.\n Filter placed today through left groin, due to extensive time in angio\n attending unable to perform surgery today, pt is on the list for\n tomorrow a.m.\n Pmh-Diabetes/Htn/Etoh abuse/? Hep C/ Hiv. Pt stated at one point to RN\n pt had diagnoses then denied.\n .\n Fracture, other\n Assessment:\n Pt with rt humerus fx and left tib/fib fx that need fixing in OR. Pt\n with few other ortho fx\ns which will not require surgery. Per request\n pt needs a IVC filter prior to OR. Plans for pt to go to OR today for\n ORIF\n Action:\n Ivc filter 1130-1330 in angio, OR cancelled due to extensive time in\n angio. Left groin drsg, pulse checks, flat till 1730\n Response:\n No changes, extremities warm, palp pulses.\n Plan:\n Cont to monitor, plan for OR in a.m. Splint to left leg and sling on\n Delirium / confusion\n Assessment:\n Pt with extensive hx of ETOH. Confused, agitated, much improved over\n last couple of days.\n Action:\n Ciwa scale as ordered/ Ativan/ Left arm in restraint due to pulling at\n tubes. Re-oriented and bed alarm for fall risk. Pt does not need a\n sitter currently.\n Response:\n Pt\ns mental status improved, oriented to self , hosp and at times yr.\n Remains restrained currently\n Plan:\n Cont to closely monitor, ciwa scale as ordered\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436047, "text": "HPI: 48 yr old male who initially slipped on ice while walking one week\n prior to getting struck by car. He had gone to an OSH and had sustained\n a right humerus and the abrasions on his knuckles. He later been\n discharged and sent home with a scheduled date to come back and have a\n scheduled ORIF.\n Unsure of how many days later per reports of family it happened to be\n the following day pt was walking down his street and was struck by a\n car. Unknown speed. + ETOH +LOC, found unresponsive with FS 20-30,\n given 1 Amp D50 and transferred to on for further\n management. Pt was then sent to cc6 from ED on \n Injuries include: Rt humeral neck fx, left distal tib/fib fx, right\n femoral greater trochanteric fx's, right superior and inferior pubic\n rami fx's, right sacral fx, L2-L3 left transverse process fx. Found to\n have multiple fractures but ortho surgery deferred due to elevated INR\n of 1.5.\n Pt triggered on floor for low blood sugars, change in mental status,\n also hct fell from 26.9 on admission to 19 , unclear source of bleeding\n as CT torso did not show hematoma. Transferred to TSICU for\n monitoring. Pt stable in Tsicu, consulted. Plan for Or today,\n but per request of trauma pt get and IVC filter prior to surgery.\n Filter placed today through left groin, due to extensive time in angio\n attending unable to perform surgery today, pt is on the list for\n tomorrow a.m.\n Pmh-Diabetes/Htn/Etoh abuse/? Hep C/ Hiv. Pt stated at one point to RN\n pt had diagnoses then denied.\n .\n Fracture, other\n Assessment:\n Pt with rt humerus fx and left tib/fib fx that need fixing in OR. Pt\n with few other ortho fx\ns which will not require surgery. Per request\n pt needs a IVC filter prior to OR. Plans for pt to go to OR today for\n ORIF\n Action:\n Ivc filter 1130-1330 in angio, OR cancelled due to extensive time in\n angio. Left groin drsg, pulse checks, flat till 1730\n Response:\n No changes, extremities warm, palp pulses.\n Plan:\n Cont to monitor, plan for OR in a.m. Splint to left leg and sling on\n Delirium / confusion\n Assessment:\n Pt with extensive hx of ETOH. Confused, agitated, much improved over\n last couple of days.\n Action:\n Ciwa scale as ordered/ Ativan/ Left arm in restraint due to pulling at\n tubes. Re-oriented and bed alarm for fall risk. Pt does not need a\n sitter currently.\n Response:\n Pt\ns mental status improved, oriented to self , hosp and at times yr.\n Remains restrained currently\n Plan:\n Cont to closely monitor, ciwa scale as ordered\n Impaired Skin Integrity\n Assessment:\n Pt has stage 1 to right heel.\n Action:\n Foot in multipodis boot, barrier cream.\n Response:\n No changes\n Plan:\n Cont to closely monitor\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436048, "text": "HPI: 48 yr old male who initially slipped on ice while walking one week\n prior to getting struck by car. He had gone to an OSH and had sustained\n a right humerus and the abrasions on his knuckles. He later been\n discharged and sent home with a scheduled date to come back and have a\n scheduled ORIF.\n Unsure of how many days later per reports of family it happened to be\n the following day pt was walking down his street and was struck by a\n car. Unknown speed. + ETOH +LOC, found unresponsive with FS 20-30,\n given 1 Amp D50 and transferred to on for further\n management. Pt was then sent to cc6 from ED on \n Injuries include: Rt humeral neck fx, left distal tib/fib fx, right\n femoral greater trochanteric fx's, right superior and inferior pubic\n rami fx's, right sacral fx, L2-L3 left transverse process fx. Found to\n have multiple fractures but ortho surgery deferred due to elevated INR\n of 1.5.\n Pt triggered on floor for low blood sugars, change in mental status,\n also hct fell from 26.9 on admission to 19 , unclear source of bleeding\n as CT torso did not show hematoma. Transferred to TSICU for\n monitoring. Pt stable in Tsicu, consulted. Plan for Or today,\n but per request of trauma pt get and IVC filter prior to surgery.\n Filter placed today through left groin, due to extensive time in angio\n attending unable to perform surgery today, pt is on the list for\n tomorrow a.m.\n Pmh-Diabetes/Htn/Etoh abuse/? Hep C/ Hiv. Pt stated at one point to RN\n pt had diagnoses then denied.\n Pt cleared to go out to floor, report given to RN CC6\n .\n Fracture, other\n Assessment:\n Pt with rt humerus fx and left tib/fib fx that need fixing in OR. Pt\n with few other ortho fx\ns which will not require surgery. Per request\n pt needs a IVC filter prior to OR. Plans for pt to go to OR today for\n ORIF\n Action:\n Ivc filter 1130-1330 in angio, OR cancelled due to extensive time in\n angio. Left groin drsg, pulse checks, flat till 1730\n Response:\n No changes, extremities warm, palp pulses.\n Plan:\n Cont to monitor, plan for OR in a.m. Splint to left leg and sling on\n Delirium / confusion\n Assessment:\n Pt with extensive hx of ETOH. Confused, agitated, much improved over\n last couple of days.\n Action:\n Ciwa scale as ordered/ Ativan/ Left arm in restraint due to pulling at\n tubes. Re-oriented and bed alarm for fall risk. Pt does not need a\n sitter currently.\n Response:\n Pt\ns mental status improved, oriented to self , hosp and at times yr.\n Remains restrained currently\n Plan:\n Cont to closely monitor, ciwa scale as ordered\n Impaired Skin Integrity\n Assessment:\n Pt has stage 1 to right heel.\n Action:\n Foot in multipodis boot, barrier cream.\n Response:\n No changes\n Plan:\n Cont to closely monitor\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436057, "text": "HPI: 48 yr old male who initially slipped on ice while walking one week\n prior to getting struck by car. He had gone to an OSH and had sustained\n a right humerus and the abrasions on his knuckles. He later been\n discharged and sent home with a scheduled date to come back and have a\n scheduled ORIF.\n Unsure of how many days later per reports of family it happened to be\n the following day pt was walking down his street and was struck by a\n car. Unknown speed. + ETOH +LOC, found unresponsive with FS 20-30,\n given 1 Amp D50 and transferred to on for further\n management. Pt was then sent to cc6 from ED on \n Injuries include: Rt humeral neck fx, left distal tib/fib fx, right\n femoral greater trochanteric fx's, right superior and inferior pubic\n rami fx's, right sacral fx, L2-L3 left transverse process fx. Found to\n have multiple fractures but ortho surgery deferred due to elevated INR\n of 1.5.\n Pt triggered on floor for low blood sugars, change in mental status,\n also hct fell from 26.9 on admission to 19 , unclear source of bleeding\n as CT torso did not show hematoma. Transferred to TSICU for\n monitoring. Pt stable in Tsicu, consulted. Plan for Or today,\n but per request of trauma pt get and IVC filter prior to surgery.\n Filter placed today through left groin, due to extensive time in angio\n attending unable to perform surgery today, pt is on the list for\n tomorrow a.m.\n Pmh-Diabetes/Htn/Etoh abuse/? Hep C/ Hiv. Pt stated at one point to RN\n pt had diagnoses then denied.\n Pt cleared to go out to floor, report given to RN CC6\n .\n Fracture, other\n Assessment:\n Pt with rt humerus fx and left tib/fib fx that need fixing in OR. Pt\n with few other ortho fx\ns which will not require surgery. Per request\n pt needs a IVC filter prior to OR. Plans for pt to go to OR today for\n ORIF\n Action:\n Ivc filter 1130-1330 in angio, OR cancelled due to extensive time in\n angio. Left groin drsg, pulse checks, flat till 1730\n Response:\n No changes, extremities warm, palp pulses.\n Plan:\n Cont to monitor, plan for OR in a.m. Splint to left leg and sling on\n Delirium / confusion\n Assessment:\n Pt with extensive hx of ETOH. Confused, agitated, much improved over\n last couple of days.\n Action:\n Ciwa scale as ordered/ Ativan/ Left arm in restraint due to pulling at\n tubes. Re-oriented and bed alarm for fall risk. Pt does not need a\n sitter currently.\n Response:\n Pt\ns mental status improved, oriented to self , hosp and at times yr.\n Remains restrained currently\n Plan:\n Cont to closely monitor, ciwa scale as ordered\n Impaired Skin Integrity\n Assessment:\n Pt has stage 2 to right heel.\n Action:\n Foot in multipodis boot, barrier cream.\n Response:\n No changes\n Plan:\n Cont to closely monitor, follow skin closely.\n" }, { "category": "Nursing", "chartdate": "2179-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435713, "text": "42 yo man pedestrian vs car +ETOH +LOC found unresponsive with FS 20-30\n given d50 and transferred . Injuriens R humeral neck fx displaced,\n R greater trochanteric fx, b/l superior rami fx, R inf rami fx, ? L inf\n rami fx, L2-3 TP fx, ant compression deformity T4. Ortho deferred\n surgery due to elevated INR of 1.5. Hct had fallen from 26.9 to 19\n he was transfused 2 uprbc. He had a CT of torso which did not\n show hematoma and he was transferred to TSICU for closer monitoring. He\n also had a change in MS on the floor CIWA scale in place.\n Delirium / confusion\n Assessment:\n Auditory and visual hallucinations, very agitated at times, restless,\n suspicious, ciwa scale 20. Pupils equal and reactive, mae, fc. Pt\n grimacing to movement especially of his left leg. Left leg ant calf\n area of 4x2cm edematous, erythematous and ankle, foot edematous 2mm >\n than right pedal pulses +\n Action:\n Tx per ciwa scale with ativan 1mg IV. Tx with 1mg iv dilaudid for pain\n Response:\n Ciwa scale < 10, able to move in bed with less pain\n Plan:\n Monitor ciwa scale tx prn, medicate for pain, monitor area on left leg\n MD \nmia (Volume Depletion - without shock)\n Assessment:\n Hct 29.2 after 2uprbc, bp stable INR 1.2\n Action:\n Checking hct INR\n Response:\n Hct stable\n Plan:\n Monitor hct, hr, bp, INR\n Hypoglycemia\n Assessment:\n Blood sugars 141, 164\n Action:\n Tx per ss insulin\n Response:\n Plan:\n Tx per ss insulin check FS q 6\n" }, { "category": "Social Work", "chartdate": "2179-02-09 00:00:00.000", "description": "Social Work Admission Note", "row_id": 435795, "text": "Family Information\n Next of : (mother) \n Health Care Proxy appointed: Proxy\n Family Spokesperson designated: (mother)\n Communication or visitation restriction: none\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Independent\n Previous or other hospital admissions: visit to ED w/ETOH in\n .\n Past psychiatric history: none known\n Past addictions history: Pt +ETOH w/BAL=184 upon admit; h/o ETOH abuse\n per chart.\n Employment status: Disabled & pursuing SSDI\n Legal involvement: none known\n Mandated Reporting Information: n/a\n Additional Information:\n Patient / Family Assessment: Pt is 47 yr-old male adm on truama\n services s/p ped struck. Pt trans from OSH (). Injuries are\n orthopedic, multi fxs. Pt currently in TSICU to manage DTs & MS\n changes, is on CIWA. Disc w/RN, . Spoke by phone with pt\ns mother,\n , who is tearful, very upset about not being able to be with pt\n in hosp due to financial difficulties and inability to come to \n from . She reports that in addition to pt, another son lives\n at home with her and 3^rd son lives on his own. She says she hopes to\n be able to get a ride with son & come to hosp tomorrow. She reports\n that pt does not work due to DMII and is trying to get SSDI.\n SW provided contact info as well as emotional support around practical\n issues. Normalized reactions to difficult situation. Will continue to\n follow.\n Clergy Contact: Name: deferred\n Communication with Team:\n Primary Nurse: \n / Follow up:\n Continuing issues to be addressed: Will continue to follow pt/family\n to assess coping, provide support. Will address ETOH abuse issues and\n reactions to trauma w/pt when he is able to participate in discussion.\n Please page PRN.\n , LICSW\n #\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 435927, "text": "Delirium / confusion\n Assessment:\n Disoriented, confused, combative since last night, trying to pull lines\n out\n Action:\n Ativan +PRN, restrained, trying to reorient patient\n Response:\n Slept most of the night with Dilodid/ativan administration\n Plan:\n Reorient patient, manage DTs with ativan, adequate pain management\n Fracture, other\n Assessment:\n Bilateral femur fx, r. shoulder fx, L foot fx\n Action:\n Repositioning often, pain control, elevation of extremities\n Response:\n Pt slept on and off,\n Plan:\n" }, { "category": "Physician ", "chartdate": "2179-02-09 00:00:00.000", "description": "Intensivist Note", "row_id": 435765, "text": "SICU\n HPI:\n HPI:42M pedestrian vs car at unknown speed. + ETOH +LOC, found\n unresponsive with FS 20-30, given 1 Amp D50 and transferred to on\n for further management. Found to have multiple fractures but\n ortho surgery deferred due to elevated INR of 1.5. Hct fell from 26.9\n on admission to 19 today, unclear source of bleeding as CT torso did\n not show hematoma. Transferred to TICU for monitoring.\n .\n ISSUES:\n ETOH withdrawal\n Agitation\n erratic blood sugar control\n Dropping Hct- unknown source of bleeding vs dilutional?\n Injuries:\n R humeral neck fx displaced,\n R Greater trochanteric fx\n B/L superior rami fx, R inf rami fx,\n ? L inf rami fx, L2-L3 TP fx\n Ant compression deformity T4 .\n .\n EVENTS:\n .\n 24 HOUR EVENTS:\n : Admitted to TICU- received 2 prbcs, lorazepam/ SEWA scale,\n consulted Josline Fellow re: glucose control.\n .\n :\n Amitriptyline 25 PM, tramadol 50\", Actos 15', Metformin 1000\", lunesta\n 3 PM, Lyrica 75\", percocet PRN\n .\n SURGICAL Hx: unknown\n .\n SOCIAL Hx: Heavy ETOH history\n .\n ALLERGIES: NKDA\n .\n EKG:\n .\n ABX: None\n .\n MICRO:\n : MRSA screening pending\n .\n IMAGING:\n .\n : HUMERUS (AP & LAT) RIGHT: Abnormal signal within the right\n aspect of the sacrum for which recommend\n correlation with CT\n CTOH : no ICH/fx\n CT C-spine : no fx, DJD with mild central canal narrowing\n CT Torso : R Sup and inf pubic rami fx and L Sup pubic\n ramus fx, with small b/l hematomas adjacent to the bladder, Acute\n comminuted fx of the R greater trochanter. Old L greater trochanteric\n fx, Acute nondisplaced fx along anterior R sacrum, Comminuted fx\n through the R humeral head and neck, Ant wedge compression deformity of\n T12 of indeterminate age, Acute L L2 and L3 TP fx. Atrophic pancreas\n with coarse calcifications representing sequelae from\n chronic pancreatitis. Increased number of mediastinal, retroperitoneal\n and mesenteric lymph nodes. Atherosclerotic disease with extensive\n vascular calcifications along the peripheral arteries, for example, the\n iliac and femoral arteries.\n MRI of CTL spine: Prevertebral and retropharyngeal edema extending from\n the skull base to approximately C4. No definite fx is noted, no\n abnormalities of Ant/Post Long Ligaments, no fx of T spine, mild\n chronic compression deformity of L1, without significant retropulsion\n into the canal. Abnormal signal within the right aspect of the sacrum\n for which recommend\n correlation with CT.\n Chief complaint:\n CHIEF COMPLAINT: falling hematocrit, risk of DTs, low blood sugars\n PMHx:\n MEDICAL:\n DM2, ETOH abuse, neuropathy, previous hip fx, lumbar spine fx, right\n non-displaced humeral neck fx 4-5 days ago, ?HIV and Hep C\n Current medications:\n CURRENT MEDICATIONS: Insulin SC Sliding Scale, 20 mEq Potassium\n Chloride / 1000 mL D5NS 75 ml/hr, Lorazepam 1-2 mg IV Q1H:PRN SEWA>10,\n Amitriptyline 25 mg PO HS, Magnesium Sulfate IV Sliding Scale, Calcium\n Gluconate IV Sliding Scale, Metoprolol Tartrate 5 mg IV Q6H,\n Multivitamins, Famotidine 20 mg IV Q12H, Potassium Chloride IV Sliding\n Scale, FoLIC Acid 1 mg IV Q24H, Potassium Phosphate IV Sliding Scale,\n HYDROmorphone (Dilaudid) 0.5-2 mg IV Q2H:PRN pain, Pregabalin 75 mg PO\n BID, Heparin 5000 UNIT SC BID, Thiamine 100 mg IV DAILY\n 24 Hour Events:\n MULTI LUMEN - START 11:55 AM\n C-SPINE CLEARANCE - At 03:18 PM\n by trauma resident\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 03:19 PM\n Famotidine (Pepcid) - 08:17 PM\n Metoprolol - 12:23 AM\n Lorazepam (Ativan) - 04:09 AM\n Hydromorphone (Dilaudid) - 04:09 AM\n Other medications:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 36.3\nC (97.4\n HR: 115 (96 - 121) bpm\n BP: 157/93(109) {131/36(45) - 164/117(127)} mmHg\n RR: 25 (12 - 25) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,501 mL\n 511 mL\n PO:\n Tube feeding:\n IV Fluid:\n 871 mL\n 511 mL\n Blood products:\n 630 mL\n Total out:\n 1,110 mL\n 510 mL\n Urine:\n 1,110 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 391 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: intermittent agitation\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli, No(t) Tactile stimuli, No(t) Noxious\n stimuli, No(t) Unresponsive), Moves all extremities, tender left shin,\n not calf\n Labs / Radiology\n 230 K/uL\n 10.9 g/dL\n 164 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 10 mg/dL\n 96 mEq/L\n 131 mEq/L\n 29.8 %\n 4.6 K/uL\n [image002.jpg]\n 08:39 PM\n 03:08 AM\n WBC\n 4.6\n Hct\n 29.2\n 29.8\n Plt\n 230\n Creatinine\n 0.6\n Glucose\n 131\n 164\n Other labs: PT / PTT / INR:13.7//1.2, ALT / AST:22/34, Alk-Phos / T\n bili:66/1.9, Albumin:3.1 g/dL, LDH:400 IU/L, Ca:8.4 mg/dL, Mg:2.2\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION, HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK),\n HYPOGLYCEMIA\n Assessment and Plan: .\n ASSESSMENT AND PLAN:42 y/o M with alcohol withdrawal, confusion,\n multiple orthopedic fractures post MVA with dropping transferred to\n TICU for hemodynamic mnitoring and alcohol withdrwal treatment.\n Neurologic: Pain control, CIWA scale with lorazepam for ETOH\n withdrawal. C-spine cleared by ortho trauma\n Neuro checks Q:2H\n Pain: Dilaudid prn\n Cardiovascular: Hemodynamically stable\n Pulmonary: No acute issues\n Gastrointestinal / Abdomen:: no active issues, check LFTs\n Nutrition: NPO currently\n Renal: Monitor UO and Cr\n Hematology: :q12H Hct\n Endocrine: consult for diabetes recommended loosening , \n need insulin post discharge due to chronic pancreatitis.\n Infectious Disease: No active issues\n Lines / Tubes / Drains: PIV, foley\n Wounds: : otho trauma following to perform ORIF of right humerus\n when more stable.right arm in sling\n Imaging: CXR today\n Fluids: change to D5NS at 75cc/hr\n Consults : trauma, ortho, diabetes center\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:55 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32\n" }, { "category": "Physician ", "chartdate": "2179-02-09 00:00:00.000", "description": "Intensivist Note", "row_id": 435697, "text": "SICU\n HPI:\n HPI:42M pedestrian vs car at unknown speed. + ETOH +LOC, found\n unresponsive with FS 20-30, given 1 Amp D50 and transferred to on\n for further management. Found to have multiple fractures but\n ortho surgery deferred due to elevated INR of 1.5. Hct fell from 26.9\n on admission to 19 today, unclear source of bleeding as CT torso did\n not show hematoma. Transferred to TICU for monitoring.\n .\n ISSUES:\n ETOH withdrawal\n Agitation\n erratic blood sugar control\n Dropping Hct- unknown source of bleeding vs dilutional?\n Injuries:\n R humeral neck fx displaced,\n R Greater trochanteric fx\n B/L superior rami fx, R inf rami fx,\n ? L inf rami fx, L2-L3 TP fx\n Ant compression deformity T4 .\n .\n EVENTS:\n .\n 24 HOUR EVENTS:\n : Admitted to TICU- received 2 prbcs, lorazepam/ SEWA scale,\n consulted Josline Fellow re: glucose control.\n .\n :\n Amitriptyline 25 PM, tramadol 50\", Actos 15', Metformin 1000\", lunesta\n 3 PM, Lyrica 75\", percocet PRN\n .\n SURGICAL Hx: unknown\n .\n SOCIAL Hx: Heavy ETOH history\n .\n ALLERGIES: NKDA\n .\n EKG:\n .\n ABX: None\n .\n MICRO:\n : MRSA screening pending\n .\n IMAGING:\n .\n : HUMERUS (AP & LAT) RIGHT: Abnormal signal within the right\n aspect of the sacrum for which recommend\n correlation with CT\n CTOH : no ICH/fx\n CT C-spine : no fx, DJD with mild central canal narrowing\n CT Torso : R Sup and inf pubic rami fx and L Sup pubic\n ramus fx, with small b/l hematomas adjacent to the bladder, Acute\n comminuted fx of the R greater trochanter. Old L greater trochanteric\n fx, Acute nondisplaced fx along anterior R sacrum, Comminuted fx\n through the R humeral head and neck, Ant wedge compression deformity of\n T12 of indeterminate age, Acute L L2 and L3 TP fx. Atrophic pancreas\n with coarse calcifications representing sequelae from\n chronic pancreatitis. Increased number of mediastinal, retroperitoneal\n and mesenteric lymph nodes. Atherosclerotic disease with extensive\n vascular calcifications along the peripheral arteries, for example, the\n iliac and femoral arteries.\n MRI of CTL spine: Prevertebral and retropharyngeal edema extending from\n the skull base to approximately C4. No definite fx is noted, no\n abnormalities of Ant/Post Long Ligaments, no fx of T spine, mild\n chronic compression deformity of L1, without significant retropulsion\n into the canal. Abnormal signal within the right aspect of the sacrum\n for which recommend\n correlation with CT.\n Chief complaint:\n CHIEF COMPLAINT: falling hematocrit, risk of DTs, low blood sugars\n PMHx:\n MEDICAL:\n DM2, ETOH abuse, neuropathy, previous hip fx, lumbar spine fx, right\n non-displaced humeral neck fx 4-5 days ago, ?HIV and Hep C\n Current medications:\n CURRENT MEDICATIONS: Insulin SC Sliding Scale, 20 mEq Potassium\n Chloride / 1000 mL D5NS 75 ml/hr, Lorazepam 1-2 mg IV Q1H:PRN SEWA>10,\n Amitriptyline 25 mg PO HS, Magnesium Sulfate IV Sliding Scale, Calcium\n Gluconate IV Sliding Scale, Metoprolol Tartrate 5 mg IV Q6H,\n Multivitamins, Famotidine 20 mg IV Q12H, Potassium Chloride IV Sliding\n Scale, FoLIC Acid 1 mg IV Q24H, Potassium Phosphate IV Sliding Scale,\n HYDROmorphone (Dilaudid) 0.5-2 mg IV Q2H:PRN pain, Pregabalin 75 mg PO\n BID, Heparin 5000 UNIT SC BID, Thiamine 100 mg IV DAILY\n 24 Hour Events:\n MULTI LUMEN - START 11:55 AM\n C-SPINE CLEARANCE - At 03:18 PM\n by trauma resident\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 03:19 PM\n Famotidine (Pepcid) - 08:17 PM\n Metoprolol - 12:23 AM\n Lorazepam (Ativan) - 04:09 AM\n Hydromorphone (Dilaudid) - 04:09 AM\n Other medications:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 36.3\nC (97.4\n HR: 115 (96 - 121) bpm\n BP: 157/93(109) {131/36(45) - 164/117(127)} mmHg\n RR: 25 (12 - 25) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,501 mL\n 511 mL\n PO:\n Tube feeding:\n IV Fluid:\n 871 mL\n 511 mL\n Blood products:\n 630 mL\n Total out:\n 1,110 mL\n 510 mL\n Urine:\n 1,110 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 391 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: intermittent agitation\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli, No(t) Tactile stimuli, No(t) Noxious\n stimuli, No(t) Unresponsive), Moves all extremities, tender left shin,\n not calf\n Labs / Radiology\n 230 K/uL\n 10.9 g/dL\n 164 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 10 mg/dL\n 96 mEq/L\n 131 mEq/L\n 29.8 %\n 4.6 K/uL\n [image002.jpg]\n 08:39 PM\n 03:08 AM\n WBC\n 4.6\n Hct\n 29.2\n 29.8\n Plt\n 230\n Creatinine\n 0.6\n Glucose\n 131\n 164\n Other labs: PT / PTT / INR:13.7//1.2, ALT / AST:22/34, Alk-Phos / T\n bili:66/1.9, Albumin:3.1 g/dL, LDH:400 IU/L, Ca:8.4 mg/dL, Mg:2.2\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n DELIRIUM / CONFUSION, HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK),\n HYPOGLYCEMIA\n Assessment and Plan: .\n ASSESSMENT AND PLAN:42 y/o M with alcohol withdrawal, confusion,\n multiple orthopedic fractures post MVA with dropping transferred to\n TICU for hemodynamic mnitoring and alcohol withdrwal treatment.\n Neurologic: NEUROLOGIC:Pain control, SEWA scale with lorazepam for ETOH\n withdrawal. C-spine cleared by ortho trauma\n Neuro checks Q:2H\n Pain: Dilaudid prn\n Cardiovascular: CARDIOVASCULAR: Hemodynamically stable\n Pulmonary: PULMONARY: No acute issues\n Gastrointestinal / Abdomen: GI / ABD: no active issues, check LFTs\n Nutrition: NUTRITION: NPO currently\n Renal: RENAL: Monitor UO and Cr\n Hematology:\n HEMATOLOGY:q12H Hct\n Endocrine: ENDOCRINE: consult for diabetes recommended\n loosening , need insulin post discharge due to chronic\n pancreatitis.\n Infectious Disease: ID: No active issues\n Lines / Tubes / Drains: LINES/TUBES/DRAINS: PIV, foley\n Wounds: : otho trauma following to perform ORIF of right humerus\n when more stable.\n WOUNDS: right arm in sling\n Imaging: CXR today\n Fluids: FLUIDS: change to D5NS at 75cc/hr\n Consults: CONSULTS: trauma, ortho, diabetes center\n Billing Diagnosis: Multiple injuries (Trauma)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:55 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436029, "text": "HPI: 48 yr old male who initially slipped on ice while walking one week\n prior to getting struck by car. He had gone to an OSH and had sustained\n a right humerus and the abrasions on his knuckles. He later been\n discharged and sent home with a scheduled date to come back and have a\n scheduled ORIF.\n Unsure of how many days later per reports of family it happened to be\n the following day pt was walking down his street and was struck by a\n car. Unknown speed. + ETOH +LOC, found unresponsive with FS 20-30,\n given 1 Amp D50 and transferred to on for further\n management. Pt was then sent to cc6 from ED on \n Injuries include: Rt humerus fx, left tib/fib fxFound to have multiple\n fractures but ortho surgery deferred due to elevated INR of 1.5. Hct\n fell from 26.9 on admission to 19 today, unclear source of bleeding as\n CT torso did not show hematoma. Transferred to TICU for monitoring.\n .\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2179-02-10 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 436006, "text": "24 Hour Events:\n HPI: 42M pedestrian vs car at unknown speed. + ETOH +LOC, found\n unresponsive with FS 20-30, given 1 Amp D50 and transferred to on\n for further management. Found to have multiple fractures but\n ortho surgery deferred due to elevated INR of 1.5. Hct fell from 26.9\n on admission to 19 today, unclear source of bleeding as CT torso did\n not show hematoma. Transferred to TICU for monitoring.\n .\n CHIEF COMPLAINT: falling hematocrit, risk of DTs, low blood sugars,\n mult fractures\n .\n CURRENT MEDICATIONS: Insulin SC, Lorazepam 1-2 mg IV Q1H:PRN CIWA>10,\n Amitriptyline 25 mg PO HS, Lorazepam 1 mg IV Q4HR, Metoprolol Tartrate\n 5 mg IV Q6H, Famotidine 20 mg IV Q12H, FoLIC Acid 1 mg IV Q24H,\n HYDROmorphone 0.5-2 mg IV Q2H:PRN pain, Pregabalin 75 mg PO BID,\n Heparin 5000 UNIT SC BID, Thiamine 100 mg IV DAILY\n .\n 24 HOUR EVENTS:\n : Hct stable, mental status clearing and requiring minimal amts of\n ativan, left tib/fib fx -> ortho consulted --> to OR for repair of\n tib/fib and humeral fx; trauma wants IR to place IVC \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:59 PM\n Metoprolol - 06:06 PM\n Famotidine (Pepcid) - 08:06 PM\n Heparin Sodium (Prophylaxis) - 08:06 PM\n Lorazepam (Ativan) - 08:06 PM\n Other medications:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 73 (73 - 104) bpm\n BP: 121/77(88) {121/77(88) - 177/125(131)} mmHg\n RR: 10 (9 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.6 kg (admission): 56 kg\n Total In:\n 1,980 mL\n 425 mL\n PO:\n TF:\n IVF:\n 1,980 mL\n 425 mL\n Blood products:\n Total out:\n 1,670 mL\n 320 mL\n Urine:\n 1,670 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 310 mL\n 105 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n GEN: WD, WN, NAD\n Neuro: orientated to person, follows commands\n Chest: CTAB, no w/c/r\n Cards: RRR, no m/r/g\n Abd: soft, nt, nd, nabs\n Ext: LLE with mild edema\n in splint, RLE in multipodis boot\n pulses\n intact\n Labs / Radiology\n 261 K/uL\n 10.8 g/dL\n 143 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 100 mEq/L\n 134 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n 08:39 PM\n 03:08 AM\n 11:45 AM\n 02:26 AM\n WBC\n 4.6\n 3.9\n Hct\n 29.2\n 29.8\n 30.4\n 30.8\n Plt\n 230\n 261\n Cr\n 0.6\n 0.5\n Glucose\n 131\n 164\n 143\n Other labs: PT / PTT / INR:14.0/29.6/1.2, ALT / AST:22/34, Alk Phos / T\n Bili:66/1.9, Albumin:3.1 g/dL, LDH:400 IU/L, Ca++:8.2 mg/dL, Mg++:1.5\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 42 y/o M with alcohol withdrawal, confusion,\n multiple orthopedic fractures post MVA with dropping transferred to\n TICU for hemodynamic monitoring and alcohol withdrwal treatment.\n NEUROLOGIC: Pain control, CIWA scale with lorazepam for ETOH\n withdrawal. C-spine cleared by ortho trauma\n Neuro checks Q: 4H\n Pain: Dilaudid prn\n CARDIOVASCULAR: Hemodynamically stable\n PULMONARY: encourage IS\n GI / ABD: check LFTs\n NUTRITION: NPO currently in prep for OR\n RENAL: Monitor UO and Cr\n HEMATOLOGY: qday Hct\n ENDOCRINE: consult for diabetes recommended loosening , \n need insulin post discharge due to chronic pancreatitis.\n ID: monitor WBC\n LINES/TUBES/DRAINS: PIV, foley\n : otho trauma following to perform ORIF of right humerus / L\n tib/fib \n WOUNDS: right arm in sling when out of bed; non-wt bearing LLE\n IMAGING: none\n FLUIDS: change to D5NS at 75cc/hr\n CONSULTS: trauma, ortho, diabetes center\n BILLING DIAGNOSIS: multiple trauma\n ICU Care\n Nutrition: NPO for OR today\n Glycemic Control: \n Lines:\n Multi Lumen - 11:55 AM\n 20 Gauge - 12:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: transfer to floor\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2179-02-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 436024, "text": "HPI: 48 yr old male who initially slipped on ice while walking one week\n prior to getting struck by car. He had gone to an OSH and had sustained\n a right humerus and the abrasions on his knuckles. He later been\n discharged and sent home with a scheduled date to come back and have a\n scheduled ORIF.\n Unsure of how many days later per reports of family it happened to be\n the following day pt was walking down his street and was struck by a\n car. Unknown speed. + ETOH +LOC, found unresponsive with FS 20-30,\n given 1 Amp D50 and transferred to on for further\n management. Pt was then sent to cc6 from ED on \n Injuries include: Rt humerus fx, left tib/fib fxFound to have multiple\n fractures but ortho surgery deferred due to elevated INR of 1.5. Hct\n fell from 26.9 on admission to 19 today, unclear source of bleeding as\n CT torso did not show hematoma. Transferred to TICU for monitoring.\n .\n Fracture, other\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-02-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 435849, "text": "Delirium / confusion\n Assessment:\n A&Ox1-2 (person, sometimes\nhospital\n). Converses semi-appropriately\n about his injuries and need for surgery. CIWA maintained <10 with\n standing ativan 1mg IV q4. MAE with normal strength relative to\n injuries. PERRL 2mm. Gag, cough intact.\n Action:\n CIWA scale. Ativan 1mg IV q4 with PRN for CIWA>10\n Response:\n No additional ativan needed this shift, remains safe.\n Plan:\n Continue CIWA, orientation.\n Fracture, other\n Assessment:\n Noted swelling, redness, painful left ankle.\n Action:\n Xrays ordered. Dilaudid prn for pain. LLE splinted by Dr .\n Response:\n Comminuted proximal fibular fracture and comminuted spiral distal\n fibula fractures identified. Comfortable at rest, req\nd only one dose\n of Dilaudid this shift.\n Plan:\n OR tomorrow with orthopedics for left distal tibia and right arm.\n" }, { "category": "Physician ", "chartdate": "2179-02-10 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 435960, "text": "24 Hour Events:\n HPI: 42M pedestrian vs car at unknown speed. + ETOH +LOC, found\n unresponsive with FS 20-30, given 1 Amp D50 and transferred to on\n for further management. Found to have multiple fractures but\n ortho surgery deferred due to elevated INR of 1.5. Hct fell from 26.9\n on admission to 19 today, unclear source of bleeding as CT torso did\n not show hematoma. Transferred to TICU for monitoring.\n .\n CHIEF COMPLAINT: falling hematocrit, risk of DTs, low blood sugars,\n mult fractures\n .\n CURRENT MEDICATIONS: Insulin SC, Lorazepam 1-2 mg IV Q1H:PRN CIWA>10,\n Amitriptyline 25 mg PO HS, Lorazepam 1 mg IV Q4HR, Metoprolol Tartrate\n 5 mg IV Q6H, Famotidine 20 mg IV Q12H, FoLIC Acid 1 mg IV Q24H,\n HYDROmorphone 0.5-2 mg IV Q2H:PRN pain, Pregabalin 75 mg PO BID,\n Heparin 5000 UNIT SC BID, Thiamine 100 mg IV DAILY\n .\n 24 HOUR EVENTS:\n : Hct stable, mental status clearing and requiring minimal amts of\n ativan, left tib/fib fx -> ortho consulted --> to OR for repair of\n tib/fib and humeral fx; trauma wants IR to place IVC \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:59 PM\n Metoprolol - 06:06 PM\n Famotidine (Pepcid) - 08:06 PM\n Heparin Sodium (Prophylaxis) - 08:06 PM\n Lorazepam (Ativan) - 08:06 PM\n Other medications:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 73 (73 - 104) bpm\n BP: 121/77(88) {121/77(88) - 177/125(131)} mmHg\n RR: 10 (9 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.6 kg (admission): 56 kg\n Total In:\n 1,980 mL\n 425 mL\n PO:\n TF:\n IVF:\n 1,980 mL\n 425 mL\n Blood products:\n Total out:\n 1,670 mL\n 320 mL\n Urine:\n 1,670 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 310 mL\n 105 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n GEN: WD, WN, NAD\n Neuro: orientated to person, follows commands\n Chest: CTAB, no w/c/r\n Cards: RRR, no m/r/g\n Abd: soft, nt, nd, nabs\n Ext: LLE with mild edema\n in splint, RLE in multipodis boot\n pulses\n intact\n Labs / Radiology\n 261 K/uL\n 10.8 g/dL\n 143 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 100 mEq/L\n 134 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n 08:39 PM\n 03:08 AM\n 11:45 AM\n 02:26 AM\n WBC\n 4.6\n 3.9\n Hct\n 29.2\n 29.8\n 30.4\n 30.8\n Plt\n 230\n 261\n Cr\n 0.6\n 0.5\n Glucose\n 131\n 164\n 143\n Other labs: PT / PTT / INR:14.0/29.6/1.2, ALT / AST:22/34, Alk Phos / T\n Bili:66/1.9, Albumin:3.1 g/dL, LDH:400 IU/L, Ca++:8.2 mg/dL, Mg++:1.5\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 42 y/o M with alcohol withdrawal, confusion,\n multiple orthopedic fractures post MVA with dropping transferred to\n TICU for hemodynamic mnitoring and alcohol withdrwal treatment.\n .\n NEUROLOGIC: Pain control, CIWA scale with lorazepam for ETOH\n withdrawal. C-spine cleared by ortho trauma\n Neuro checks Q: 4H\n Pain: Dilaudid prn\n CARDIOVASCULAR: Hemodynamically stable\n PULMONARY: No acute issues\n GI / ABD: no active issues, check LFTs\n NUTRITION: NPO currently in prep for OR\n RENAL: Monitor UO and Cr\n HEMATOLOGY: q12H Hct\n ENDOCRINE: consult for diabetes recommended loosening , \n need insulin post discharge due to chronic pancreatitis.\n ID: No active issues\n LINES/TUBES/DRAINS: PIV, foley\n : otho trauma following to perform ORIF of right humerus / L\n tib/fib \n WOUNDS: right arm in sling when out of bed; non-wt bearing LLE\n IMAGING:\n FLUIDS: change to D5NS at 75cc/hr\n CONSULTS: trauma, ortho, diabetes center\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: \n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: yes\n CODE STATUS: FULL\n DISPOSITION: call out to floor s/p OR today\n ICU Care\n Nutrition: NPO for OR today\n Glycemic Control: \n Lines:\n Multi Lumen - 11:55 AM\n 20 Gauge - 12:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2179-02-10 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 435975, "text": "24 Hour Events:\n HPI: 42M pedestrian vs car at unknown speed. + ETOH +LOC, found\n unresponsive with FS 20-30, given 1 Amp D50 and transferred to on\n for further management. Found to have multiple fractures but\n ortho surgery deferred due to elevated INR of 1.5. Hct fell from 26.9\n on admission to 19 today, unclear source of bleeding as CT torso did\n not show hematoma. Transferred to TICU for monitoring.\n .\n CHIEF COMPLAINT: falling hematocrit, risk of DTs, low blood sugars,\n mult fractures\n .\n CURRENT MEDICATIONS: Insulin SC, Lorazepam 1-2 mg IV Q1H:PRN CIWA>10,\n Amitriptyline 25 mg PO HS, Lorazepam 1 mg IV Q4HR, Metoprolol Tartrate\n 5 mg IV Q6H, Famotidine 20 mg IV Q12H, FoLIC Acid 1 mg IV Q24H,\n HYDROmorphone 0.5-2 mg IV Q2H:PRN pain, Pregabalin 75 mg PO BID,\n Heparin 5000 UNIT SC BID, Thiamine 100 mg IV DAILY\n .\n 24 HOUR EVENTS:\n : Hct stable, mental status clearing and requiring minimal amts of\n ativan, left tib/fib fx -> ortho consulted --> to OR for repair of\n tib/fib and humeral fx; trauma wants IR to place IVC \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:59 PM\n Metoprolol - 06:06 PM\n Famotidine (Pepcid) - 08:06 PM\n Heparin Sodium (Prophylaxis) - 08:06 PM\n Lorazepam (Ativan) - 08:06 PM\n Other medications:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 73 (73 - 104) bpm\n BP: 121/77(88) {121/77(88) - 177/125(131)} mmHg\n RR: 10 (9 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55.6 kg (admission): 56 kg\n Total In:\n 1,980 mL\n 425 mL\n PO:\n TF:\n IVF:\n 1,980 mL\n 425 mL\n Blood products:\n Total out:\n 1,670 mL\n 320 mL\n Urine:\n 1,670 mL\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 310 mL\n 105 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n GEN: WD, WN, NAD\n Neuro: orientated to person, follows commands\n Chest: CTAB, no w/c/r\n Cards: RRR, no m/r/g\n Abd: soft, nt, nd, nabs\n Ext: LLE with mild edema\n in splint, RLE in multipodis boot\n pulses\n intact\n Labs / Radiology\n 261 K/uL\n 10.8 g/dL\n 143 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 10 mg/dL\n 100 mEq/L\n 134 mEq/L\n 30.8 %\n 3.9 K/uL\n [image002.jpg]\n 08:39 PM\n 03:08 AM\n 11:45 AM\n 02:26 AM\n WBC\n 4.6\n 3.9\n Hct\n 29.2\n 29.8\n 30.4\n 30.8\n Plt\n 230\n 261\n Cr\n 0.6\n 0.5\n Glucose\n 131\n 164\n 143\n Other labs: PT / PTT / INR:14.0/29.6/1.2, ALT / AST:22/34, Alk Phos / T\n Bili:66/1.9, Albumin:3.1 g/dL, LDH:400 IU/L, Ca++:8.2 mg/dL, Mg++:1.5\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 42 y/o M with alcohol withdrawal, confusion,\n multiple orthopedic fractures post MVA with dropping transferred to\n TICU for hemodynamic monitoring and alcohol withdrwal treatment.\n NEUROLOGIC: Pain control, CIWA scale with lorazepam for ETOH\n withdrawal. C-spine cleared by ortho trauma\n Neuro checks Q: 4H\n Pain: Dilaudid prn\n CARDIOVASCULAR: Hemodynamically stable\n PULMONARY: encourage IS\n GI / ABD: check LFTs\n NUTRITION: NPO currently in prep for OR\n RENAL: Monitor UO and Cr\n HEMATOLOGY: qday Hct\n ENDOCRINE: consult for diabetes recommended loosening , \n need insulin post discharge due to chronic pancreatitis.\n ID: monitor WBC\n LINES/TUBES/DRAINS: PIV, foley\n : otho trauma following to perform ORIF of right humerus / L\n tib/fib \n WOUNDS: right arm in sling when out of bed; non-wt bearing LLE\n IMAGING: none\n FLUIDS: change to D5NS at 75cc/hr\n CONSULTS: trauma, ortho, diabetes center\n BILLING DIAGNOSIS: multiple trauma\n ICU Care\n Nutrition: NPO for OR today\n Glycemic Control: \n Lines:\n Multi Lumen - 11:55 AM\n 20 Gauge - 12:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: transfer to floor\n Total time spent: 31 minutes\n" }, { "category": "Radiology", "chartdate": "2179-02-05 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1055943, "text": " 9:56 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male status post pedestrian hit by MVC, trauma.\n\n COMPARISON: None available. CT abdomen/pelvis images performed at outside\n hospital were reviewed on CD ROM.\n\n AP SUPINE CHEST RADIOGRAPH: Study is limited by underlying trauma board and\n overlying medical devices. Allowing for supine technique, the\n cardiomediastinal and hilar contours are likely normal. Lungs are moderately\n well inflated and streaky opacities in the lung bases could represent\n atelectasis. No supine evidence for large pneumothorax or pleural effusion is\n seen. No displaced rib fractures are evident. Comminuted, displaced\n fractures through the right humeral head and neck are incompletely visualized.\n Contrast is seen within the renal collecting systems.\n\n IMPRESSION: Right humeral neck fracture. Otherwise, no definite evidence for\n intrathoracic injury seen.\n\n" }, { "category": "Radiology", "chartdate": "2179-02-09 00:00:00.000", "description": "L TIB/FIB (AP & LAT) LEFT", "row_id": 1056428, "text": " 8:32 AM\n TIB/FIB (AP & LAT) LEFT Clip # \n Reason: please eval for fracture\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with L ankle swelling, redness, s/p mvc\n REASON FOR THIS EXAMINATION:\n please eval for fracture\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw 12:15 PM\n Comminuted proximal fibular fracture. Comminuted spiral distal tibia fracture\n with equivocal transverse fracture through the posterior medial malleolus.\n Ankle mortise appears congruent but would recommend dedicated ankle films for\n further evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left ankle swelling and redness status post motor vehicle collision,\n evaluate for fracture.\n\n FOUR RADIOGRAPHS OF THE LEFT TIBIA AND FIBULA.\n\n FINDINGS: No direct comparisons are available. Minimally displaced and\n angulated fracture of the proximal fibula with a 1.5-cm butterfly fragment\n anteriorly.\n\n FINDINGS: There is a comminuted spiral fracture of the distal tibia. Seen\n only on the lateral radiograph is an equivocal transverse fracture through the\n posterior cortex of the medial malleolus. The ankle mortise appears\n congruent, however we would recommend further evaluation with ankle\n radiographs. There is soft tissue swelling around the medial and lateral\n malleolus. The lateral malleolus appears intact. There are extensive\n vascular calcifications. Limited views of the knee appear normal. No\n sclerotic, lytic or erosive changes are present. No radiopaque foreign bodies\n are seen. Incidental note is made of an os peronei.\n\n IMPRESSION: Comminuted minimally angulated and displaced proximal fibular\n fracture. Comminuted spiral minimally angulated and displaced distal tibia\n fracture with equivocal fracture of the posterior medial malleolus. No intra-\n articular extension is seen. The ankle mortise appears congruent, but would\n recommend further evaluation with ankle films.\n\n" }, { "category": "Radiology", "chartdate": "2179-02-09 00:00:00.000", "description": "L TIB/FIB (AP & LAT) LEFT", "row_id": 1056429, "text": ", F. TSICU 8:32 AM\n TIB/FIB (AP & LAT) LEFT Clip # \n Reason: please eval for fracture\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with L ankle swelling, redness, s/p mvc\n REASON FOR THIS EXAMINATION:\n please eval for fracture\n ______________________________________________________________________________\n PFI REPORT\n Comminuted proximal fibular fracture. Comminuted spiral distal tibia fracture\n with equivocal transverse fracture through the posterior medial malleolus.\n Ankle mortise appears congruent but would recommend dedicated ankle films for\n further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2179-02-09 00:00:00.000", "description": "L ANKLE (AP, MORTISE & LAT) LEFT", "row_id": 1056523, "text": " 1:29 PM\n ANKLE (AP, MORTISE & LAT) LEFT Clip # \n Reason: please assess ankle mortise\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with left prox tib and distal fib fx - no dedicated ankle films\n done\n REASON FOR THIS EXAMINATION:\n please assess ankle mortise\n ______________________________________________________________________________\n FINAL REPORT\n LEFT ANKLE \n\n CLINICAL INFORMATION: Left proximal tibial and distal fibular fracture\n without dedicated ankle film.\n\n FINDINGS:\n\n Comparison is made to the prior tibial and fibular films. Three views of the\n left ankle are submitted. There is a comminuted fracture of the distal tibia\n with a moderate medial angulation of the major distal fracture fragment. The\n fracture does not appear to be intra-articular. Tibiotalar joint appears to\n be intact as does the mortise in the talar dome. Distal fibula also appears\n to be intact. There is moderate bimalleolar soft tissue swelling. There is a\n questionable nondisplaced fracture through the superior aspect of the medial\n malleolus. Fracture appears to extend into the posterior malleolus as well,\n but there is no definite extension into the tibiotalar joint.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-02-10 00:00:00.000", "description": "INTERUP IVC", "row_id": 1056705, "text": " 11:29 AM\n IVC GRAM/FILTER Clip # \n Reason: Patient is going to OR in afternoon, please do early AM \n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n Contrast: OPTIRAY Amt: 75\n ********************************* CPT Codes ********************************\n * INTERUP IVC INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with pelvic, L2-3 fractures, right humerus, right trochanter\n fracture\n REASON FOR THIS EXAMINATION:\n Patient is going to OR in afternoon, please do early AM \n ______________________________________________________________________________\n WET READ: AGLc WED 2:42 PM\n successful placement of retrievable infrarenal IVC filter.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURES:\n 1. Inferior vena cavagram.\n 2. Placement of inferior vena cava filter.\n 3. Follow-up inferior vena cavagram.\n\n HISTORY: 47-year old male with left tibia/fibula, bilateral pubic rami, right\n greater trochanteric, and right proximal humeral fractures after pedestrian\n vs. MVC injury. Here for prophylactic IVC filter placement prior to ORIF\n planned for same day.\n\n ATTENDING:\n RESIDENT: Dr. .\n\n SEDATION: Patient was sedated on the floor with ativan; no further sedation\n was administered during the procedure.\n\n CONTRAST: 75 cc of 60% Optiray. Total fluoroscopy time 6 min.\n\n DEVICE: Bard G2 femoral vena cava filter set, lot #.\n\n PROCEDURE DESCRIPTION: The risks, benefits, and alternatives of venography and\n inferior vena cava filter placement were discussed with the patient's mother,\n Mrs. ; informed consent was given over the telephone, and documented in\n the patient's chart.\n\n The patient was brought to the angiography suite, and the left groin was\n prepped and draped in standard sterile fashion. After local anesthesia with 1%\n lidocaine, the left common femoral vein was accessed with an 21-gauge\n micropuncture needle and a 4.5 french micropuncture sheath was placed over a\n 018 inch nitinol wire. The micropuncture sheath was exchanged for a 4 french\n omniflush catheter was then inserted into the inferior vena cava over a 0.035\"\n wire to the level of the iliac venous confluence. Diagnostic\n (Over)\n\n 11:29 AM\n IVC GRAM/FILTER Clip # \n Reason: Patient is going to OR in afternoon, please do early AM \n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n venography was performed, and the position of the renal veins was noted. While\n the right common femoral vein did not opacify during the cavogram, it appeared\n patent on subsequent hand injection.\n\n The pigtail catheter was exchanged over the wire for the filter introducer\n sheath. A Bard G2 vena cava filter was inserted via the introducer and\n carefully deployed under fluoroscopy below the confluence of the renal veins.\n Follow-up venography was performed through the introducer sheath, which was\n subsequently removed. Hemostasis was obtained at the venotomy site with manual\n compression. A sterile dressing was applied. The patient tolerated the\n procedure well without immediate complication and was transported back to the\n trauma ICU in stable condition.\n\n FINDINGS:\n 1. Normal inferior vena cavogram, with patency of right common iliac vein\n demonstrated on hand injection. IVC diameter less than 28 mm. No anatomic\n anamolies or evidence of intraluminal thrombus.\n 2. Successful placement of a retrievable inferior vena cava filter via the\n left common femoral vein.\n 3. Follow-up venography showed the filter centered in the lumen of the IVC\n below the confluence of the renal veins and no extravasation.\n\n IMPRESSIONS:\n 1. Successful placement of retrievable Bard G2 inferior vena cava filter.\n 2. Normal inferior vena cavagram.\n 3. The filter may be removed after the patient has recovered and no longer\n requires DVT prophylaxis or once he is able to be anticoagulated.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2179-02-05 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1055944, "text": " 10:07 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: PED STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man ped struck by car\n REASON FOR THIS EXAMINATION:\n eval for trauma\n CONTRAINDICATIONS for IV CONTRAST:\n unknown cr\n ______________________________________________________________________________\n WET READ: AGLc 11:08 PM\n no acute fracture or malalignment seen. degenerative changes, with C3-4 C4-5\n canal narrowing. if suspect cord injury, MR recommended.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male pedestrian struck by car, intoxicated.\n\n COMPARISON: None available. CT head was performed concomitantly.\n\n TECHNIQUE: MDCT axial imaging was performed through the cervical spine\n without administration of IV contrast. Multiplanar reformatted images were\n then obtained.\n\n CT C-SPINE: No evidence of acute fracture or malalignment concerning for\n ligamentous injury, or paravertebral hematoma is seen.\n\n There is fusion of the vertebral bodies of C6 and C7 as well as fusion of the\n posterior elements at these levels. Degenerative changes are most marked at\n the C4-5 and C5-6 levels where there are posterior osteophytes as well as\n diffuse disc bulges causing canal narrowing, particularly at the C4-5 level\n where the disc bulge touches the anterior aspect of the thecal sac.\n\n Limited views through the skull base show no gross abnormality. Neck nodes\n are small. The visualized lung apices appear unremarkable.\n\n IMPRESSION:\n 1. No evidence of acute fracture or malalignment seen.\n 2. Degenerative changes with mild central canal narrowing as described above.\n If there is concern for cord injury, MR would be recommended for more\n sensitive evaluation.\n\n Findings were initially discussed with the trauma team including Dr. ,\n and posted on the ED dashboard via CCC.\n\n" }, { "category": "Radiology", "chartdate": "2179-02-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1055945, "text": " 10:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: PED STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man ped struck by car\n REASON FOR THIS EXAMINATION:\n eval for trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AGLc 11:04 PM\n no acute intracranial injury seen. chronic sinus mucosal disease.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male pedestrian struck by car, intoxicated with alcohol.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT axial imaging was performed through the brain without\n administration of IV contrast.\n\n NON-CONTRAST HEAD CT: No evidence of acute intracranial hemorrhage, edema,\n mass effect, hydrocephalus, or large vascular territorial infarction is seen.\n Mild prominence of the extra-axial CSF spaces and the ventricles may be\n slightly more than expected for the patient's age. The soft tissues and\n orbits appear intact. The patient has had bilateral lens replacement. No\n skull fracture is seen. Mastoid air cells are well aerated. Mucosal\n thickening is noted throughout the visualized paranasal sinuses, without\n evidence of layering fluid.\n\n IMPRESSION:\n 1. No evidence of acute intracranial traumatic injury seen.\n 2. Mucosal thickening througout paranasal sinuses, consistent with chronic\n sinus disease.\n\n Findings were initially discussed with trauma team including Dr. as\n well as posted on the ED dashboard upon completion of the study.\n\n" }, { "category": "Radiology", "chartdate": "2179-02-05 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1055946, "text": " 10:09 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: PED STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man ped struck by car\n REASON FOR THIS EXAMINATION:\n eval for trauma\n CONTRAINDICATIONS for IV CONTRAST:\n unknown cr;unknown cr\n ______________________________________________________________________________\n WET READ: AGLc 11:11 PM\n right humeral neck fracture. right femoral greater trochanteric fractures.\n right sup & inf pubic rami fractures. left sup pubic rami fracture. small\n hematoma adjacent to bladder; bladder without leak of contrast. suspect non-\n displaced right sacral fracture, anteriorly along SI joint. left transverse\n fractures at L2, L3. anterior wedge deformity at T12, age indeterminate.\n chronic fracture fragment of left greater trochanter.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male pedestrian struck by car, intoxicated.\n\n COMPARISON: Images from CT abdomen/pelvis performed at outside hospital,\n available on CD ROM.\n\n TECHNIQUE: MDCT axial imaging was performed through the chest, abdomen and\n pelvis without administration of IV contrast, as patient had already received\n IV contrast bolus for initial trauma at the time of initial CT abdomen and\n pelvis performed at outside hospital. Multiplanar reformatted images were\n also obtained.\n\n CT CHEST WITHOUT IV CONTRAST: No evidence of pneumothorax, pleural or\n pericardial effusion is seen. The non-opacified heart and great vessels are\n unremarkable except to note mural calcifications along the aortic knob and\n aortic valve calcifications. Aside from dependent atelectatic changes, areas\n of plate-like atelectasis are noted in the lung bases bilaterally. No\n evidence of pulmonary contusion is seen. The central airways remain patent.\n Multiple non-pathologically enlarged lymph nodes are noted in the\n supraclavicular and mediastinal regions. For example, the largest superior\n mediastinal lymph node measures 9 mm in short axis in the precarinal station.\n A larger right paraesophageal lymph node measures 13 mm. Small amount of\n fluid is noted in the distal esophagus.\n\n CT ABDOMEN WITHOUT IV CONTRAST: The non-enhanced liver, gallbladder, spleen,\n adrenal glands, and right kidney appear unremarkable. Incidental note is made\n of a splenule. IV contrast material is seen within the collecting system and\n ureters which appear intact. 18-mm cyst is noted in the interpolar region of\n the left kidney. Smaller 9-mm hypodensity in the upper pole of the left\n kidney is too small to accurately characterize but also likely represents a\n cyst. The pancreas is diffusely atrophic with coarse calcifications likely\n due to chronic pancreatitis.\n\n (Over)\n\n 10:09 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: PED STRUCK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The stomach is moderately distended with fluid. The non-enhanced small bowel\n is nondistended and appears unremarkable. Moderate stool is noted within the\n colon which otherwise appears unremarkable. No free air or free fluid is\n noted within the abdomen. Atherosclerotic calcifications are noted along the\n abdominal aorta, which maintains normal caliber. Dense calcifications are\n noted in smaller peripheral arteries, for example, the iliac and femoral\n arteries. Numerous small mesenteric lymph nodes are noted, not meeting CT\n size criteria for adenopathy.\n\n CT PELVIS WITH IV CONTRAST: The urinary bladder is nondistended with Foley\n catheter in place; it also contains IV contrast without evidence of leak. The\n prostate, seminal vesicles, and non- opacified rectosigmoid colon appears\n unremarkable. Note is made of bilateral fat- containing inguinal hernias.\n\n OSSEOUS STRUCTURES: There are minimally displaced right superior and inferior\n pubic rami fractures, as well as non-displaced superior pubic ramus fracture\n on the left. High- density material adjacent to the bladder, slightly more on\n the left, likely represent small hematomas resulting from these pelvic\n fractures. Additionally, there is nondisplaced fracture through the anterior\n right sacrum, along the sacroiliac joint, without extension into the sacral\n foramina.\n\n Acute comminuted fractures are noted through the greater trochanter of the\n right femur, adjacent to a region of soft tissue stranding. Well-corticated\n fragment on the left is consistent with old left greater trochanteric\n fracture.\n\n Minimally displaced fracture is noted through the left transverse process of\n L3 and nondisplaced fracture is noted through the left transverse process of\n L2.\n\n Slight irregular contour to the posterior aspect of the left twelfth rib,\n without adjacent pleural or soft tissue abnormality, could represent an old\n rib fracture. Anterior wedge compression deformity of T12 is of indeterminate\n chronicity. Multilevel degenerative changes are also noted throughout the\n spine, with Schmorl's node formation along the superior endplate of T10.\n\n Comminuted fractures are noted through the right humeral head and neck, with\n medial displacement and posterior angulation of the major distal fracture\n fragment, also with some degree of overriding. The glenohumeral articulation\n appears preserved. There may be intra-articular extension of fracture into\n the inferior right humeral head. There is associated soft tissue swelling and\n hematoma.\n\n IMPRESSIONS:\n 1. Right superior and inferior pubic rami fractures and left superior pubic\n (Over)\n\n 10:09 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: PED STRUCK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ramus fracture, with small bilateral hematomas adjacent to the bladder.\n 2. Acute comminuted fracture of the right greater trochanter. Old left\n greater trochanteric fracture.\n 3. Acute nondisplaced fracture along anterior right sacrum, adjacent to the\n sacroiliac joint.\n 4. Comminuted fractures through the right humeral head and neck.\n 5. Anterior wedge compression deformity of T12 of indeterminate age. Acute\n left L2 and L3 transverse process fractures.\n 6. Moderately distended stomach; placement of NG tube for decompression is\n recommended.\n 7. Atrophic pancreas with coarse calcifications representing sequelae from\n chronic pancreatitis.\n 8. Increased number of mediastinal, retroperitoneal and mesenteric lymph\n nodes.\n 9. Atherosclerotic disease with extensive vascular calcifications along the\n peripheral arteries, for example, the iliac and femoral arteries.\n\n Findings were initially discussed with the trauma team including Dr. .\n Findings were also posted on the ED dashboard upon completion of the study.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-02-07 00:00:00.000", "description": "MR THORACIC SPINE W/O CONTRAST", "row_id": 1056109, "text": " 9:52 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: ? T12 fracture\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with backpain\n REASON FOR THIS EXAMINATION:\n ? T12 fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb 2:14 PM\n Mild compression deformity of L1 without significant retropulsion into the\n canal.\n\n Abnormal signal within the right aspect of the sacrum, recommend correlation\n with CT for further evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE THORACIC AND LUMBAR SPINE\n\n HISTORY: Back pain, question T12 fracture. The patient has history of\n trauma.\n\n In the thoracic spine, there is no evidence of acute compression fracture.\n There is a Schmorl's node at the superior aspect of T11.\n There is a chronic compression deformity at L1, without significant\n retropulsion into the canal. There is a lumbarized S1 with a disc space\n between S1 and S2. There is mild facet hypertrophy in the lower lumbar spine.\n No significant central stenosis is seen. There is abnormal signal within the\n right aspect of the sacrum, the etiology of which is unclear on this\n examination. Recommend correlation with CT for further evaluation.\n There is a 20-mm cyst in the left kidney. There is bilateral mild scarring in\n the lung fields.\n\n IMPRESSION:\n\n No significant abnormality in the thoracic spine. There is mild chronic\n compression deformity of L1, without significant retropulsion into the canal.\n\n Abnormal signal within the right aspect of the sacrum for which recommend\n correlation with CT.\n\n\n\n\n\n\n (Over)\n\n 9:52 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: ? T12 fracture\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2179-02-07 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1056073, "text": " 2:15 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: r/o acute cervical trauma.\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man pedestrian struck by car, R humeral fx and pelvic fx. CT\n C-Spine negative, but c/o pain and midline tenderness. in c-collar.\n REASON FOR THIS EXAMINATION:\n r/o acute cervical trauma.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb 3:08 PM\n No definite fracture. Multilevel cervical spondylosis. Prevertebral and\n retropharyngeal edema extending from the skull base to approximately C4.\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE CERVICAL SPINE WITHOUT GADOLINIUM\n\n HISTORY: Trauma.\n\n Comparison is made with CT performed on .\n\n There is straightening of the normal cervical lordosis.\n\n There is a disc osteophyte complex at C3-C4, which causes mild central and\n bilateral foraminal narrowing.\n\n At C4-C5, there is a disc osteophyte complex which causes mild central and\n bilateral moderate foraminal narrowing.\n\n At C5-C6, there is a disc osteophyte complex which causes bilateral moderate\n foraminal narrowing.\n\n At C6-C7, there is partial fusion of the disc space. There is no significant\n stenosis.\n\n At C7-T1, there is no significant stenosis.\n\n\n There is prevertebral and retropharyngeal edema from the skull base to\n approximately C4, but no definite evidence for increase signal in the anterior\n or posterior longitudinal ligaments is seen.\n\n There is no cord contusion seen.\n\n IMPRESSION:\n\n Prevertebral and retropharyngeal edema extending from the skull base to\n approximately C4. No definite fracture is noted, however. There is no\n evidence for increased signal along the anterior and posterior longitudinal\n ligament.\n\n (Over)\n\n 2:15 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: r/o acute cervical trauma.\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2179-02-07 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1056074, "text": ", F. CC6A 2:15 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: r/o acute cervical trauma.\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man pedestrian struck by car, R humeral fx and pelvic fx. CT\n C-Spine negative, but c/o pain and midline tenderness. in c-collar.\n REASON FOR THIS EXAMINATION:\n r/o acute cervical trauma.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No definite fracture. Multilevel cervical spondylosis. Prevertebral and\n retropharyngeal edema extending from the skull base to approximately C4.\n\n" }, { "category": "Radiology", "chartdate": "2179-02-07 00:00:00.000", "description": "MR THORACIC SPINE W/O CONTRAST", "row_id": 1056110, "text": ", F. CC6A 9:52 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: ? T12 fracture\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with backpain\n REASON FOR THIS EXAMINATION:\n ? T12 fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Mild compression deformity of L1 without significant retropulsion into the\n canal.\n\n Abnormal signal within the right aspect of the sacrum, recommend correlation\n with CT for further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2179-02-11 00:00:00.000", "description": "OL TIB/FIB (AP & LAT) IN O.R. LEFT", "row_id": 1056902, "text": " 9:49 AM\n TIB/FIB (AP & LAT) IN O.R. LEFT; HUMERUS (AP & LAT) IN O.R. RIGHTClip # \n Reason: ORIF L TIBIA/ ORIF R HUMERUS\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: Left tib-fib intraoperative study and right shoulder intraoperative\n study, .\n\n FINDINGS: Single image of the left tib-fib demonstrates the superior portion\n of a large fracture plate in the distal tibia. The inferior aspect of the\n hardware and ankle is not included in the field of view. Please refer to the\n operative note for additional details.\n\n Eight additional fluoroscopic images of the right shoulder show a fracture\n involving the surgical neck of the right proximal humerus. There is a\n prominent fracture plate with multiple associated cortical screws fixating the\n fracture. No signs for hardware-related complications are identified. Please\n refer to the operative note for additional details.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2179-02-05 00:00:00.000", "description": "R HUMERUS (AP & LAT) RIGHT", "row_id": 1055951, "text": " 10:40 PM\n HUMERUS (AP & LAT) RIGHT; ELBOW (AP, LAT & OBLIQUE) RIGHT Clip # \n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT\n Reason: eval for trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man ped struck by car\n REASON FOR THIS EXAMINATION:\n eval for trauma\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male pedestrian struck by car, intoxicated.\n\n COMPARISON: CT torso performed 10 minutes prior.\n\n RIGHT SHOULDER, THREE VIEWS: There is transverse fracture through the right\n humeral neck with comminuted fracture extending into the humeral head. Most of\n the glenohumeral articulation appears preserved, however, there may be\n extension of the fracture into the intra-articular surface inferiorly. There\n is medial displacement and overriding of the distal fracture fragment. No\n fracture is seen in the clavicle or scapula, and the acromioclavicular joint\n appears preserved. No displaced rib fractures are noted in the visualized\n right upper chest.\n\n RIGHT HUMERUS, TWO VIEWS: No other fractures are noted within the remainder\n of the humerus other than that described above involving the proximal humerus.\n\n RIGHT ELBOW, TWO VIEWS: No evidence of acute fracture, dislocation, or large\n joint effusion is seen. Vascular calcifications are noted.\n\n IMPRESSION: Comminuted fracture through the right humeral head and neck with\n overriding and medial displacement of the major distal fracture fragment.\n\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2179-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056399, "text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess lung fields\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with multiple injuries post MVA\n REASON FOR THIS EXAMINATION:\n assess lung fields\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multiple injuries after MVA, to evaluate for pulmonary disease.\n\n FINDINGS: The lateral half of the left lung has been excluded from the image.\n No gross evidence of acute cardiopulmonary disease. Complex fracture of the\n right humeral head is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-02-06 00:00:00.000", "description": "CT UP EXT W/O C", "row_id": 1056007, "text": " 9:30 AM\n CT UP EXT W/O C Clip # \n Reason: Please do 3d reconstructions after scan, ortho will need the\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man pedest vs car, has displaced right humeral neck fracture.\n REASON FOR THIS EXAMINATION:\n Please do 3d reconstructions after scan, ortho will need the scans before the\n OR\n CONTRAINDICATIONS for IV CONTRAST:\n Recieved IV contrast at OSH\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT right shoulder.\n\n TECHNIQUE: Axial CT images of the right shoulder were obtained with selected\n sagittal and coronal reformats, without intravenous contrast. No priors for\n comparison.\n\n HISTORY: Trauma.\n\n FINDINGS: There is a severely comminuted fracture of the proximal humerus.\n The fracture extends into the greater and lesser tuberosities, as well as\n surgical neck. The greatest degree of comminution appears to be in the\n surgical neck region. Multiple fragments are displaced, including comminuted\n greater tuberosity fragments which are displaced approximately 5 mm. The\n surgical neck is also displaced medially approximately 1.4 cm. There is no\n current evidence of glenohumeral dislocation.\n\n Acromioclavicular degenerative changes are identified. There is a large\n amount of muscular edema surrounding the fracture site.\n\n Vascular calcifications are noted. There are shotty mediastinal nodes, which\n are seen to better advantage on the concurrent CT torso study.\n\n Glenohumeral degenerative changes are also noted.\n\n Thoracic spine degenerative changes are partially visualized.\n\n IMPRESSION:\n\n 1. Comminuted fracture of proximal humerus, involving the surgical neck,\n greater and lesser tuberosities. No dislocation.\n\n 2. Degenerative changes in spine and shoulder as detailed.\n\n\n" }, { "category": "ECG", "chartdate": "2179-02-06 00:00:00.000", "description": "Report", "row_id": 219225, "text": "Sinus tachycardia. Poor R wave progression. Cannot rule out old anteroseptal\nmyocardial infarction. Diffuse non-specific ST-T wave abnormalities. No\nprevious tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2147-11-14 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1214932, "text": " 5:33 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: aneurysm, other acute\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with SAH\n REASON FOR THIS EXAMINATION:\n aneurysm, other acute\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa TUE 7:44 PM\n C- : no acute hemorrhage seen\n C+: no definite aneurysm. no major vascular occlusion or dissection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old woman with suspected subarachnoid hemorrhage.\n\n COMPARISON: CT head, .\n\n TECHNIQUE: Contiguous axial scans of the head were obtained without contrast.\n Following intravenous administration of contrast, MDCT scans of the head and\n neck were obtained in the arterial phase. Images were processed on a separate\n workstation with display of curved reformats, 3D volume redendered images, and\n maximum intensity projection images.\n\n FINDINGS:\n\n CT HEAD: There is no acute intracranial hemorrhage, infarction, edema, or\n mass effect seen. Again seen is a well-circumscribed hypodense cystic lesion\n with peripheral calcifications in the pineal region, likely representing a\n pineal cyst. Ventricles and sulci appear normal in size and configuration.\n Visualized paranasal sinuses, mastoid air cells, and orbits are unremarkable.\n\n CTA HEAD: Bilateral intracranial internal carotid arteries, vertebral\n arteries, basilar artery and their major branches are patent with no evidence\n of stenosis, occlusion, dissection, or aneurysm formation.\n\n CTA NECK: There is a normal three-vessel takeoff of the aortic arch. Both\n common carotid arteries and internal carotid arteries in the neck are normal\n in caliber with no evidence of stenosis, occlusion, dissection, or\n pseudoaneurysm formation. Bilateral vertebral artery origins are patent.\n Both vertebral arteries in the neck are patent with no evidence of stenosis,\n occlusion, dissection, or pseudoaneurysm formation.\n\n IMPRESSION:\n 1. No acute intracranial abnormality. Again seen is well-circumscribed\n cystic lesion with peripheral calcifications in the pineal region, likely\n representing a pineal cyst.\n 2. Unemarkable CTA of the head and neck.\n (Over)\n\n 5:33 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: aneurysm, other acute\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2147-11-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1214893, "text": " 12:16 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with sudden onset new HA\n REASON FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RJab TUE 1:50 PM\n No acute intracranial process\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old female with sudden onset new headache, question\n bleed.\n\n COMPARISONS: None.\n\n TECHNIQUE: Contiguous axial imaging was obtained through the brain without\n the administration of intravenous contrast material. Coronal and sagittal\n reformats were completed.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or\n territorial infarction. There is a 9 x 9 x 12mm well-circumscribed hypodense\n lesion with peripheral calcifications in the region of the pineal gland which\n may represent a pineal cyst. The ventricles and sulci are normal in size and\n configuration. The visualized paranasal sinuses, mastoid air cells, and\n middle ear cavities are clear. Osseous structures are unremarkable.\n\n IMPRESSION: No acute intracranial process. Well-circumscribed lesion with\n peripheral calcifications within the region of the pineal gland which may\n represent a pineal cyst. However, this is unlikely to be causing the\n patient's symptoms. Recommend non-urgent MRI for further evaluation.\n\n These findings were discussed with Dr. by Dr. via telephone at\n 4:24pm on .\n\n" } ]

[ { "category": "Radiology", "chartdate": "2160-05-08 00:00:00.000", "description": "O ABD (SINGLE VIEW ONLY) IN O.R.", "row_id": 1008621, "text": " 6:27 PM\n ABD (SINGLE VIEW ONLY) IN O.R. Clip # \n Reason: INSTRUMENT COUNT\n Admitting Diagnosis: RIGHT GROIN SARCOMA/SDA\n ______________________________________________________________________________\n WET READ: 6:58 PM\n Clips & radioopaque material project over R hip; L of L3/4 disc. Drainage\n tubes seen. GWilliams\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Instrument count.\n\n ABDOMEN, ONE VIEW: The upper abdomen is not imaged. Within this limitation,\n two likely drainage tubes are seen with a clip adjacent to the right drain\n towards the midline. A collection of clips is seen projecting over the right\n iliac bone and hip. Another tubular opacity is seen overlying the right iliac\n crest. Bowel gas pattern is nonspecific. No gross osseous abnormalities.\n\n" }, { "category": "Nursing", "chartdate": "2160-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322252, "text": "44 yo woman with a 4cmx3cm soft tissue mass sitting on right groin dx\n as synovial sarcoma s/p radiotherapy x 5wks presents for radical\n resection of sarcoma with en bloc resection of external iliac/common\n femoral artery and graft placed from common iliac to femoral artery.\n Left myofascial rectus done with inguinal ligament reconstruction and\n abd wall reconstruction. Surgery > 12hr came to icu for hourly Pulses\n DP, PT and popliteal pulses on right\n Assessment:\n Abdomen soft distended bowel sounds + incision clean and dry, JP right\n and left draining sang fluid, right femoral vac dressing intact. Pulses\n Doppler skin warm and dry\n Action:\n Monitor pulses DP,PT and popliteal q 1hr on right\n Response:\n Pt without vascular compromise\n Plan:\n Continue to monitor pulses q 1hr through the night\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Patient grimacing and holding abdomen when awake not able to use pca\n effectively\n Action:\n Encourage patient to use pca, assist when necessary\n Response:\n More comfortable\n Plan:\n Continue to monitor pain level, reinforce pca use, encourage cough and\n deep breathing use of IS\n" }, { "category": "Nursing", "chartdate": "2160-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322243, "text": "44 yo woman with a right groin synovial sarcoma s/p radiotherapy x\n 5wks presents for radical resection of sarcoma with en bloc\n resection of external iliac/common femoral artery and graft placement\n from common iliac to femoral artery. Left myofascial rectus done with\n inguinal ligament reconstruction and abd wall reconstruction. Surgery >\n 12hr came to icu for hourly Pulses DP, PT and popliteal pulses on right\n Assessment:\n Abdomen soft distended bowel sounds + incision clean and dry, JP right\n and left draining sang fluid, right femoral vac dressing intact. Pulses\n Doppler skin warm and dry\n Action:\n Monitor pulses DP,PT and popliteal q 1hr on right, hct stable\n Response:\n Pt without vascular compromise\n Plan:\n Continue to monitor pulses q 1hr through the night, monitor output jp\n and vac\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Patient grimacing and holding abdomen when awake not able to use pca\n effectively\n Action:\n Encourage patient to use pca, assist when necessary\n Response:\n More comfortable\n Plan:\n Continue to monitor pain level, reinforce pca use, encourage turn cough\n deep breathing exercise along with IS use.\n" }, { "category": "Nursing", "chartdate": "2160-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322251, "text": "44 yo woman with a right groin synovial sarcoma s/p radiotherapy x\n 5wks presents for radical resection of sarcoma with en bloc\n resection of external iliac/common femoral artery and graft placement\n from common iliac to femoral artery. Left myofascial rectus done with\n inguinal ligament reconstruction and abd wall reconstruction. Surgery >\n 12hr came to icu for hourly Pulses DP, PT and popliteal pulses on right\n Assessment:\n Abdomen soft distended bowel sounds + incision clean and dry, JP right\n and left draining sang fluid, right femoral vac dressing intact. Pulses\n +2 skin warm and dry\n Action:\n Monitor pulses DP,PT and popliteal q 1hr on right,\n Response:\n Pt without vascular compromise, hct stable\n Plan:\n Continue to monitor pulses q 1hr through the night, monitor output jp\n and vac\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Patient grimacing and holding abdomen when awake not able to use pca\n effectively\n Action:\n Encourage patient to use pca, assist when necessary\n Response:\n More comfortable\n Plan:\n Continue to monitor pain level, reinforce pca use, encourage turn cough\n deep breathing exercise along with IS use.\n" }, { "category": "Nursing", "chartdate": "2160-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322253, "text": "44 yo woman with a 4cmx3cm soft tissue mass sitting on right groin dx\n as synovial sarcoma s/p radiotherapy x 5wks presents for radical\n resection of sarcoma with en bloc resection of external iliac/common\n femoral artery and graft placed from common iliac to femoral artery.\n Left myofascial rectus done with inguinal ligament reconstruction and\n abd wall reconstruction. Surgery > 12hr came to icu for hourly Pulses\n DP, PT and popliteal pulses on right\n Assessment:\n Abdomen soft distended bowel sounds + incision clean and dry, JP right\n and left draining sang fluid, right femoral vac dressing intact. Pulses\n Doppler skin warm and dry\n Action:\n Monitor pulses DP,PT and popliteal q 1hr on right\n Response:\n Pt without vascular compromise\n Plan:\n Continue to monitor pulses q 1hr through the night\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Patient grimacing and holding abdomen when awake not able to use pca\n effectively\n Action:\n Encourage patient to use pca, assist when necessary\n Response:\n More comfortable\n Plan:\n Continue to monitor pain level, reinforce pca use, encourage cough and\n deep breathing use of IS\n" }, { "category": "Nursing", "chartdate": "2160-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322234, "text": "44 yo woman with a 4cmx3cm soft tissue mass sitting on right groin dx\n as synovial sarcoma s/p radiotherapy x 5wks presents for radical\n resection of sarcoma with en bloc resection of external iliac/common\n femoral artery and graft placed from common iliac to femoral artery.\n Left myofascial rectus done with inguinal ligament reconstruction and\n abd wall reconstruction. Surgery > 12hr came to icu for hourly Pulses\n DP, PT and popliteal pulses on right\n Assessment:\n Abdomen soft distended bowel sounds + incision clean and dry, JP right\n and left draining sang fluid, right femoral vac dressing intact. Pulses\n Doppler skin warm and dry\n Action:\n Monitor pulses DP,PT and popliteal q 1hr on right\n Response:\n Pt without vascular compromise\n Plan:\n Continue to monitor pulses q 1hr through the night\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Patient grimacing and holding abdomen when awake not able to use pca\n effectively\n Action:\n Encourage patient to use pca, assist when necessary\n Response:\n More comfortable\n Plan:\n Continue to monitor pain level, reinforce pca use\n" }, { "category": "Physician ", "chartdate": "2160-05-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322283, "text": "Chief Complaint: 44 y.o.f. with right groin synovial sarcoma with\n enscasement of external iliac vessels who underwent right radical\n resection of synovial sarcoma of right groin with en bloc resection of\n external iliac/common femoral artery and graft placed from common iliac\n to femoral artery and subsequent plastic surgery reconstruction.\n 24 Hour Events:\n ARTERIAL LINE - START 09:56 PM\n on facemask at admission; switched to nasal cannula\n - pulses palpable throughout the evening\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:44 AM\n Other medications:\n Changes to medical and family history: no changes since admission\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 78 (78 - 82) bpm\n BP: 104/59(75) {104/59(75) - 115/67(83)} mmHg\n RR: 12 (12 - 14) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,308 mL\n 1,558 mL\n PO:\n TF:\n IVF:\n 5,308 mL\n 1,558 mL\n Blood products:\n Total out:\n 1,760 mL\n 2,100 mL\n Urine:\n 620 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n 40 mL\n 200 mL\n Balance:\n 3,548 mL\n -542 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.29/45/119/25/-4\n Physical Examination\n General Appearance: Well nourished, No acute distress,\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, nasal cannula\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present), 1+ DP\n LE's\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: throughout)\n Abdominal: Soft, Tender: in R groin area, right and left abd drains in\n place draining serosanguinous fluid, right wound vac in place\n Extremities: Right: Absent, Left: Absent, right thigh with bandage\n C/D/I from flap\n Labs / Radiology\n 224 K/uL\n 10.0 g/dL\n 130 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 11 mg/dL\n 103 mEq/L\n 136 mEq/L\n 29.4 %\n 9.9 K/uL\n [image002.jpg]\n 04:52 PM\n 07:59 PM\n 08:27 PM\n 04:57 AM\n WBC\n 14.4\n 9.9\n Hct\n 30\n 33.3\n 29.4\n Plt\n 281\n 224\n Cr\n 0.6\n 0.5\n TCO2\n 23\n 23\n Glucose\n 138\n 194\n 130\n Other labs: PT / PTT / INR:11.5/26.4/1.0, Differential-Neuts:91.4 %,\n Band:0.0 %, Lymph:6.1 %, Mono:2.4 %, Eos:0.1 %, Lactic Acid:2.7 mmol/L,\n Ca++:9.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n The patient is a 44 y.o.f. with right groin synovial sarcoma with\n enscasement of external iliac vessels who underwent right radical\n resection of synovial sarcoma of right groin with en bloc resection of\n external iliac/common femoral artery and graft placed from common iliac\n to femoral artery and subsequent plastic surgery reconstruction.\n # Synovial sarcoma\n s/p right radical resection of synovial sarcoma of\n right groin with en bloc resection of external iliac/common femoral\n artery and graft placed from common iliac to femoral artery and\n subsequent failed attempt at VRAM flap and left myofascial rectus done\n with inguinal ligament reconstruction and abdominal wall\n reconstruction. No other intraoperative complications.\n - Drains in place with 100 cc drainiage\n - Pain control with PCA\n - Cefazolin per surgical team\n - ASA\n - F/U surgery, vascular, and plastic recs\n - Monitor Q1H R LE pulses- stable\n - Monitor for signs and symptoms of blood loss. HCT stable\n - call out this morning to surgical service\n # Hypothyroidism\n Levothyroxine\n # HTN\n Not on antihypertensives.\n ICU Care\n Nutrition: clear liquids\n Glycemic Control: ISS\n Lines:\n Arterial Line - 09:56 PM\n 20 Gauge - 09:58 PM\n 18 Gauge - 09:58 PM\n Prophylaxis:\n DVT: heparin sc\n Stress ulcer: famotidine\n VAP: not needed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: call out to surgical service this AM\n" }, { "category": "Nursing", "chartdate": "2160-05-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 322285, "text": "HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt with dilaudid PCA, sleeping most of shift, easily aroused, oriented\n x 3, follows commands, moving all extremites, c/o pain with\n turning/movement, Vietnamese speaking, appears to understand some\n English, diificult to assess pain # without interpreter\n Action:\n Assessing pain by facial grimacing, encouraged to use PCA, repositioned\n as needed for comfort , monitor VS/rr/sat\n Response:\n Sleeping comfortably most of shift, pain subsides fairly quick after\n reposition/movement\n Plan:\n Continue to assess pain, encourage use of PCA\n Demographics\n Attending MD:\n Admit diagnosis:\n RIGHT GROIN SARCOMA/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 64.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: dz s/p RAI, hypothyroidism, HTN, monophasic\n type high grade synovial sarcoma\n Surgery / Procedure and date: right radical resection of\n synovial sarcoma of right groin with bloc resection of external\n iliac/common femoral artery and graft placed from common iliac to\n fenoral artery, attempt vertical rectus abdominis myocutaneous flap on\n rt was make but bld supply was interrupted so left myofascial rectus\n done with inguinal ligament reconstruction and abd wall reconstruction\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n 98.9\n Arterial BP:\n S:104\n D:59\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,548 mL\n 24h total out:\n 2,100 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:57 AM\n Potassium:\n 4.2 mEq/L\n 04:57 AM\n Chloride:\n 103 mEq/L\n 04:57 AM\n CO2:\n 25 mEq/L\n 04:57 AM\n BUN:\n 11 mg/dL\n 04:57 AM\n Creatinine:\n 0.5 mg/dL\n 04:57 AM\n Glucose:\n 130 mg/dL\n 04:57 AM\n Hematocrit:\n 29.4 %\n 04:57 AM\n Finger Stick Glucose:\n 137\n 07:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2160-05-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 322278, "text": "HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Demographics\n Attending MD:\n Admit diagnosis:\n RIGHT GROIN SARCOMA/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 64.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: dz s/p RAI, hypothyroidism, HTN, monophasic\n type high grade synovial sarcoma\n Surgery / Procedure and date: right radical resection of\n synovial sarcoma of right groin with bloc resection of external\n iliac/common femoral artery and graft placed from common iliac to\n fenoral artery, attempt vertical rectus abdominis myocutaneous flap on\n rt was make but bld supply was interrupted so left myofascial rectus\n done with inguinal ligament reconstruction and abd wall reconstruction\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n 98.9\n Arterial BP:\n S:104\n D:59\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,548 mL\n 24h total out:\n 2,100 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:57 AM\n Potassium:\n 4.2 mEq/L\n 04:57 AM\n Chloride:\n 103 mEq/L\n 04:57 AM\n CO2:\n 25 mEq/L\n 04:57 AM\n BUN:\n 11 mg/dL\n 04:57 AM\n Creatinine:\n 0.5 mg/dL\n 04:57 AM\n Glucose:\n 130 mg/dL\n 04:57 AM\n Hematocrit:\n 29.4 %\n 04:57 AM\n Finger Stick Glucose:\n 137\n 07:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2160-05-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 322279, "text": "HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Demographics\n Attending MD:\n Admit diagnosis:\n RIGHT GROIN SARCOMA/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 64.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: dz s/p RAI, hypothyroidism, HTN, monophasic\n type high grade synovial sarcoma\n Surgery / Procedure and date: right radical resection of\n synovial sarcoma of right groin with bloc resection of external\n iliac/common femoral artery and graft placed from common iliac to\n fenoral artery, attempt vertical rectus abdominis myocutaneous flap on\n rt was make but bld supply was interrupted so left myofascial rectus\n done with inguinal ligament reconstruction and abd wall reconstruction\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n 98.9\n Arterial BP:\n S:104\n D:59\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,548 mL\n 24h total out:\n 2,100 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:57 AM\n Potassium:\n 4.2 mEq/L\n 04:57 AM\n Chloride:\n 103 mEq/L\n 04:57 AM\n CO2:\n 25 mEq/L\n 04:57 AM\n BUN:\n 11 mg/dL\n 04:57 AM\n Creatinine:\n 0.5 mg/dL\n 04:57 AM\n Glucose:\n 130 mg/dL\n 04:57 AM\n Hematocrit:\n 29.4 %\n 04:57 AM\n Finger Stick Glucose:\n 137\n 07:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Physician ", "chartdate": "2160-05-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322280, "text": "Chief Complaint: 44 y.o.f. with right groin synovial sarcoma with\n enscasement of external iliac vessels who underwent right radical\n resection of synovial sarcoma of right groin with en bloc resection of\n external iliac/common femoral artery and graft placed from common iliac\n to femoral artery and subsequent plastic surgery reconstruction.\n 24 Hour Events:\n ARTERIAL LINE - START 09:56 PM\n on facemask at admission; switched to nasal cannula\n - pulses palpable throughout the evening\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:44 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 78 (78 - 82) bpm\n BP: 104/59(75) {104/59(75) - 115/67(83)} mmHg\n RR: 12 (12 - 14) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,308 mL\n 1,558 mL\n PO:\n TF:\n IVF:\n 5,308 mL\n 1,558 mL\n Blood products:\n Total out:\n 1,760 mL\n 2,100 mL\n Urine:\n 620 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n 40 mL\n 200 mL\n Balance:\n 3,548 mL\n -542 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.29/45/119/25/-4\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 224 K/uL\n 10.0 g/dL\n 130 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 11 mg/dL\n 103 mEq/L\n 136 mEq/L\n 29.4 %\n 9.9 K/uL\n [image002.jpg]\n 04:52 PM\n 07:59 PM\n 08:27 PM\n 04:57 AM\n WBC\n 14.4\n 9.9\n Hct\n 30\n 33.3\n 29.4\n Plt\n 281\n 224\n Cr\n 0.6\n 0.5\n TCO2\n 23\n 23\n Glucose\n 138\n 194\n 130\n Other labs: PT / PTT / INR:11.5/26.4/1.0, Differential-Neuts:91.4 %,\n Band:0.0 %, Lymph:6.1 %, Mono:2.4 %, Eos:0.1 %, Lactic Acid:2.7 mmol/L,\n Ca++:9.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n The patient is a 44 y.o.f. with right groin synovial sarcoma with\n enscasement of external iliac vessels who underwent right radical\n resection of synovial sarcoma of right groin with en bloc resection of\n external iliac/common femoral artery and graft placed from common iliac\n to femoral artery and subsequent plastic surgery reconstruction.\n # Synovial sarcoma\n s/p right radical resection of synovial sarcoma of\n right groin with en bloc resection of external iliac/common femoral\n artery and graft placed from common iliac to femoral artery and\n subsequent failed attempt at VRAM flap and left myofascial rectus done\n with inguinal ligament reconstruction and abdominal wall\n reconstruction. No other intraoperative complications.\n - Drains in place with 100 cc drainiage\n - Pain control with PCA\n - Cefazolin per surgical team\n - ASA\n - F/U surgery, vascular, and plastic recs\n - Monitor Q1H R LE pulses- stable\n - Monitor for signs and symptoms of blood loss\n - call out this morning to surgical service\n # Hypothyroidism\n Levothyroxine\n # HTN\n Not on antihypertensives.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 09:56 PM\n 20 Gauge - 09:58 PM\n 18 Gauge - 09:58 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2160-05-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 322221, "text": "Chief Complaint: Synovial sarcoma of right groin\n HPI:\n 44 y.o.f. with HTN and s/p who p/w synovial sarcoma of right\n groin s/p resection. She was originally seen in with a\n symptomatic right groin mass. CT scan demonstrated a 3.7 x 2.9 cm soft\n tissue mass sitting on the proximal femoral vessels. Core needle\n biopsy demonstrated a monophasic-type high-grade synovial sarcoma. She\n had 5 wks of radiotherapy complete on and presents for\n resection. She was taken to the OR today where she underwent right\n radical resection of synovial sarcoma of right goirn with en bloc\n resection of external iliac/common femoral artery and graft placed from\n common iliac to femoral artery. Attempt at VRAM (vertical rectus\n abdominis myocutaneous) flap on right was made but blood supply had\n been interupted so left myofascial rectus done with inguinal ligament\n reconstruction and abdominal wall reconstruction. No intraoperative\n complications. Received 4950 fluids, 1100 urine out, EGL 250cc, and a\n dose of gentamicin, cefazolin, and vancomycin. Currently she is\n somewhat sedated and states pain is in abdomen. Unable to answer\n further questions due to somnolence, but breathing without\n difficulties.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Patient unable to provide history: Sedated, Language barrier\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n None\n Other ICU medications:\n Hep SQ\n Levothyroxine 50 mcg\n Famotidine\n ASA 81\n Zofran prn\n ACET prn\n Dilaudid PCA\n ISS\n Colace\n Other medications:\n HOME MEDS:\n Levothyroxine 100 mcg daily\n Past medical history:\n Family history:\n Social History:\n s/p radioactive iodine - on levothyroxine\n HTN\n Synovial sarcoma of right groin\n DM in mother\n Occupation: at Marshalls in the fitting room\n Drugs: None\n Tobacco: No\n Alcohol:\n Other:\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis\n Flowsheet Data as of 09:22 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,908 mL\n PO:\n TF:\n IVF:\n 4,908 mL\n Blood products:\n Total out:\n 0 mL\n 240 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,668 mL\n Respiratory\n O2 Delivery Device: Venti mask\n ABG: 7.29/45/119//-4\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, mask in place\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present), 1+ DP\n LE's\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: throughout)\n Abdominal: Soft, Tender: in R groin area, right and left abd drains in\n place draining serosanguinous fluid, right wound vac in place\n Extremities: Right: Absent, Left: Absent, right thigh with bandage\n C/D/I from flap\n Skin: Not assessed, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 138 mg/dL\n 105 mEq/L\n 3.9 mEq/L\n 136 mEq/L\n 30\n [image002.jpg]\n \n 2:33 A4/10/ 04:52 PM\n \n 10:20 P4/10/ 08:27 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 30\n TC02\n 23\n 23\n Glucose\n 138\n Other labs: Lactic Acid:2.7 mmol/L\n Assessment and Plan\n The patient is a 44 y.o.f. with right groin synovial sarcoma with\n enscasement of external iliac vessels who underwent right radical\n resection of synovial sarcoma of right groin with en bloc resection of\n external iliac/common femoral artery and graft placed from common iliac\n to femoral artery and subsequent plastic surgery reconstruction.\n # Synovial sarcoma\n s/p right radical resection of synovial sarcoma of\n right groin with en bloc resection of external iliac/common femoral\n artery and graft placed from common iliac to femoral artery and\n subsequent failed attempt at VRAM flap and left myofascial rectus done\n with inguinal ligament reconstruction and abdominal wall\n reconstruction. No other intraoperative complications.\n - Drains in place\n - Pain control with PCA\n - Cefazolin\n - ASA\n - F/U surgery, vascular, and plastic recs\n - Monitor Q1H R LE pulses\n - Monitor for signs and symptoms of blood loss\n - Plan for C.O. in a.m.\n # Hypothyroidism\n Levothyroxine\n # HTN\n Not on antihypertensives.\n ICU Care\n Nutrition: Clears\n Glycemic Control: Insulin SS\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: famotidine\n VAP: not intubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: call out in a.m.\n" }, { "category": "Nursing", "chartdate": "2160-05-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322222, "text": "44 yo woman with a synovial sarcoma right groin which was 4cmx3cm soft\n tissue mass sitting on femoral vessels s/p radiotherapy x 5wks presents\n for radical resection of soft tissue mass with en bloc resection\n of external iliac/common femoral artery and graft placed from common\n iliac to femoral artery. Left myofacial rectus done with inguinal\n ligament reconstruction and abd wall reconstruction. Surgery > 12yrs\n came to icu for hourly Pulses DP, PT and popiteal pulses on right\n Assessment:\n Abdomen soft distended bowel sounds + incision clean and dry, JP right\n and left draining sang fluid, right femoral vac dressing intact. Pulses\n Doppler skin warm and dry\n Action:\n Monitor pulses DP,PT and popiteal q 1hr on right\n Response:\n Plan:\n .H/O cancer (Malignant Neoplasm), Other\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2160-05-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322321, "text": "Chief Complaint: 44 y.o.f. with right groin synovial sarcoma with\n enscasement of external iliac vessels who underwent right radical\n resection of synovial sarcoma of right groin with en bloc resection of\n external iliac/common femoral artery and graft placed from common iliac\n to femoral artery and subsequent plastic surgery reconstruction.\n 24 Hour Events:\n ARTERIAL LINE - START 09:56 PM\n on facemask at admission; switched to nasal cannula\n - pulses palpable throughout the evening\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:44 AM\n Other medications:\n Changes to medical and family history: no changes since admission\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 78 (78 - 82) bpm\n BP: 104/59(75) {104/59(75) - 115/67(83)} mmHg\n RR: 12 (12 - 14) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,308 mL\n 1,558 mL\n PO:\n TF:\n IVF:\n 5,308 mL\n 1,558 mL\n Blood products:\n Total out:\n 1,760 mL\n 2,100 mL\n Urine:\n 620 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n 40 mL\n 200 mL\n Balance:\n 3,548 mL\n -542 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.29/45/119/25/-4\n Physical Examination\n General Appearance: Well nourished, No acute distress,\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, nasal cannula\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present), 1+ DP\n LE's\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: throughout)\n Abdominal: Soft, Tender: in R groin area, right and left abd drains in\n place draining serosanguinous fluid, right wound vac in place\n Extremities: Right: Absent, Left: Absent, right thigh with bandage\n C/D/I from flap\n Labs / Radiology\n 224 K/uL\n 10.0 g/dL\n 130 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 11 mg/dL\n 103 mEq/L\n 136 mEq/L\n 29.4 %\n 9.9 K/uL\n [image002.jpg]\n 04:52 PM\n 07:59 PM\n 08:27 PM\n 04:57 AM\n WBC\n 14.4\n 9.9\n Hct\n 30\n 33.3\n 29.4\n Plt\n 281\n 224\n Cr\n 0.6\n 0.5\n TCO2\n 23\n 23\n Glucose\n 138\n 194\n 130\n Other labs: PT / PTT / INR:11.5/26.4/1.0, Differential-Neuts:91.4 %,\n Band:0.0 %, Lymph:6.1 %, Mono:2.4 %, Eos:0.1 %, Lactic Acid:2.7 mmol/L,\n Ca++:9.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n The patient is a 44 y.o.f. with right groin synovial sarcoma with\n enscasement of external iliac vessels who underwent right radical\n resection of synovial sarcoma of right groin with en bloc resection of\n external iliac/common femoral artery and graft placed from common iliac\n to femoral artery and subsequent plastic surgery reconstruction.\n # Synovial sarcoma\n s/p right radical resection of synovial sarcoma of\n right groin with en bloc resection of external iliac/common femoral\n artery and graft placed from common iliac to femoral artery and\n subsequent failed attempt at VRAM flap and left myofascial rectus done\n with inguinal ligament reconstruction and abdominal wall\n reconstruction. No other intraoperative complications.\n - Drains in place with 100 cc drainiage\n - Pain control with PCA\n - Cefazolin per surgical team\n - ASA\n - F/U surgery, vascular, and plastic recs\n - Monitor Q1H R LE pulses- stable\n - Monitor for signs and symptoms of blood loss. HCT stable\n - call out this morning to surgical service\n # Hypothyroidism\n Levothyroxine\n # HTN\n Not on antihypertensives.\n ICU Care\n Nutrition: clear liquids\n Glycemic Control: ISS\n Lines:\n Arterial Line - 09:56 PM\n 20 Gauge - 09:58 PM\n 18 Gauge - 09:58 PM\n Prophylaxis:\n DVT: heparin sc\n Stress ulcer: famotidine\n VAP: not needed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: call out to surgical service this AM\n ------ Protected Section ------\n Ms was seen and examined with the ICU team, and I was physically\n present for key portions of the services rendered. The ICU team\ns note\n reflects my input. No changes to the PMH, SH, FH, ROS since the admit\n note by Dr. yesterday, which I reviewed. In MICU for\n frequent pulse checks. Pain well controlled, normotensive, hct stable.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:47 ------\n" } ]

[ { "category": "Nursing/other", "chartdate": "2109-03-20 00:00:00.000", "description": "Report", "row_id": 1578434, "text": "1845 CCU Admission note\n\n60 years old female admitted to EDW with dyspnea/sob, hypotension and hypoxemia. PMH pancreatic ca since , lung mets since , recent biliary stent for obstructive jaundice. Pt received ativan 2mg x2 in the EDW for restlesness which is more pronounced when her sat to 70-80%.Flagyl and ceftriaxone were administered. Chest CT done to R/O PE. According to , pt began having labored breathing on evening before admission after being transfused w/ 2u of PRBC.\nOn arrival to the unit, pt was very agitated and satting in the mid 90's.Unable to follow simple commands, ativan 1mg IV given with good effect. Pt was placed on bipap, and FiO2 100%. Crackles and exp wheezing noted upon ausculation. Currently O2 sat fluctuates in the low 90's.\nCV: Pt was bolused w/ 1700ml of NS in the EDW for hypotension. Currently BP 150's-130's/70'-90's and hr 110's in the 130's when she is agitated. No ectopy noted.\n\nGI: Pos bowel sound, no BM noted.\n\nGU: FC intact, voiding clear yellow urine.\n\nCode status: Pt is DNR\n\nSoc: Family is in the room.\n\nLabs sent and BC's drawn.\n" }, { "category": "Nursing/other", "chartdate": "2109-03-21 00:00:00.000", "description": "Report", "row_id": 1578435, "text": "ccu nursing progress note 7p-4:30am\n\n60 yo female with pmh pancreatic ca with mets to bone and lung, admitted to ew for c/o sob. pt with low o2 sats, placed on mask ventilation per pt wished not to be intubated. cpap ps 10/5 peep, fio2 100%. pt initially with sats 89-94%. pt desating immediately when mask removed. pt lethargic but arousable. very agitated and appearing uncomfortable when aroused and stimulated. given mso4 and ativan prn for agitation and discomfort. ls coarse throughout with insp/exp wheezes. rr shallow and labored. temp 101.2 on arrival to unit. per report blood cultures sent. pt started on abx and given tylenol as ordered.\n\napprox 2am noted o2 sat to be 83% on mask ventilation. prior to pt had been dni but full code. intern and resident called to speak with family. declining status and poor prognosis explained to family. family continue to state pt's wishes not to be intubated, therefore decision made to not to resuscitate pt. family came to sit by pt's bedside. pt's hemodynamic status began to quickly decline. mso4 gtt started for comfort. pt expired approx 4:30 am. family at bedside. intern called to pronounce pt. per family, pt does not have any valuables present.\n" }, { "category": "ECG", "chartdate": "2109-03-20 00:00:00.000", "description": "Report", "row_id": 112958, "text": "Sinus tachycardia. Since the previous tracing of the rate is more\nrapid. Left atrial abnormality is noted. There is also a new right\nbundle-branch block.\n\n" }, { "category": "Radiology", "chartdate": "2109-03-20 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 753571, "text": " 12:12 PM\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: STAT, r/o PE, hx pancreatic cancer, acute SOB\n Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with pancreatic cancer, acutely SOB, r/o PE\n REASON FOR THIS EXAMINATION:\n STAT, r/o PE, hx pancreatic cancer, acute SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of pancreatic and lung cancer with metastatic disease,\n acute shortness of breath, rule out PE.\n\n Comparison is made to prior study of CT chest on .\n\n TECHNIQUE: CT of the chest with IV contrast. 3D reconstruction images were\n then performed. 100 cc of Optiray was administered intravenously for fast\n bolus CTA.\n\n CTA OF THE CHEST (PE PROTOCOL): Soft-tissue windows again reveal a mass\n lesion in the right prevascular space, measuring approximately 2.3 x 2.3 cm in\n size. There are also bilateral hilar lymph nodes. There are no pleural\n effusions. There are no filling defects in the pulmonary arteries suggestive\n of pulmonary embolism. The heart, pericardium and great vessels appear\n unremarkable.\n\n Lung windows reveal diffuse reticular interstitial thickening involving all of\n the lung lobes with superimposed alveolar ground glass opacifications.\n Innumerable nodules are also present in both lungs, predominantly in the lung\n periphery. There are multifocal areas of more conglomerate air-space\n consolidations, most predominantly in the left lower lobe.\n\n Bone windows reveal multiple areas of sclerotic changes in the ribs and spine,\n consistent with metastatic disease.\n\n IMPRESSION:\n\n 1) No evidence of PE.\n\n 2) Diffuse reticular interstitial disease with ground glass air-space\n opacification and innumerable peripheral nodules, suggestive of lymphangitic\n carcinomatosis. There are multiple more conglomerate air-space\n consolidations, most predominantly in the left lower lobe. This could\n represent superimposed pneumonia or ARDS.\n\n 3) Right prevascular mediastinal nodal mass reported before is again\n visualized.\n\n 4) Multiple osseous metastatic foci.\n\n The above findings were discussed with Emergency Room house staff upon\n completion of the study.\n (Over)\n\n 12:12 PM\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: STAT, r/o PE, hx pancreatic cancer, acute SOB\n Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Radiology", "chartdate": "2200-11-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 746048, "text": " 12:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for intracranial pathology / evidence of inc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with HA, intractable N/V\n REASON FOR THIS EXAMINATION:\n Please evaluate for intracranial pathology / evidence of increased intracranial\n pressure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Headche and nausea.\n\n TECHNIQUE: Axial CT imaging of the brain without contrast enhancement.\n\n CT HEAD: There is low attenuation in both frontal lobes anteriorly, without\n change from . There is no acute intracranial hemorrhage, mass effect,\n or hydrocephalus. Burr holes are noted in both frontal bones. The paranasal\n sinuses are clear.\n\n IMPRESSION: Stable bifrontal encephalomalacia.\n\n" }, { "category": "Radiology", "chartdate": "2200-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 746333, "text": " 4:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p multiple R IJ CVL attempts. R/O PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with UGIB and reflex sympathetic dystrophy.\n REASON FOR THIS EXAMINATION:\n s/p multiple R IJ CVL attempts. R/O PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Upper GI bleed and reflex sympathetic dystrophy. Multiple right\n IJ central venous line attempts. Rule out pneumothorax.\n\n FINDINGS: A single AP supine portable rib film is provided. This is compared\n with the prior study of . There is evidence of an extremely small\n pneumothorax at the apex of the right hemithorax. The NG tube has been\n removed. There is again evidence of some left ventricular enlargement of\n the heart. Surgical clips are noted in the right paratracheal region and\n there is again a suggestion of slight widening of the superior mediastinum on\n the right side. There is also again slight patchy atelectasis in the right\n lower zone. Some clearing of the previously noted left lower zone atelectasis\n is present. The left subclavian sheath has been removed.\n\n IMPRESSION: A minute pneumothorax is present at the right apex. The\n appearances are otherwise essentially unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-11-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 746188, "text": " 1:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for pneumothorax and line placement s/p left Quartis li\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with UGIB and reflex sympathetic dystrophy.\n REASON FOR THIS EXAMINATION:\n Eval for pneumothorax and line placement s/p left Quartis line.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Upper GI bleed status post line placement.\n\n FINDINGS: Single view of the chest. Comparison study dated . There is\n an NG tube coiled within the stomach. There is a left subclavian sheath in\n place that appeaers kinked likely at the entrance underneath the clavicle. The\n tip resides within the distal left brachiocephalic vein. There is left lower\n lobe atelectasis. Underlying consolidation cannot be excluded. No\n pneumothorax is seen. There are low lung volumes. There are clips in the\n right paratracheal region, without change.\n\n IMPRESSION:\n 1) No pneumothorax.\n 2) Apparent kinking of the left subclavian sheath, positioning as above.\n\n" }, { "category": "Radiology", "chartdate": "2200-11-27 00:00:00.000", "description": "GASTRIC EMPTYING STUDY", "row_id": 746477, "text": "GASTRIC EMPTYING STUDY Clip # \n Reason: ONE WK H/O NAUSEA AND VOMITING; EVALUATE FOR GASTROPARESIS.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Forty-two year old female with reflex sympathetic dystrophy,\n Hirschsprung's disease s/p colectomy, chronic pain and h/o GI bleeding.\n Admitted for nausea and vomiting x 1 week and found to have hiatal hernia and\n blood in antrum of stomach on esophagogastroduodenoscopy. Evaluate for\n gastroparesis.\n\n INTERPRETATION:\n\n Following the oral ingestion of a meal of radiolabeled egg- whites, the patient\n was placed supine beneath the gamma camera. Multiple anterior and posterior\n images of the tracer activity in the stomach and bowel were recorded for 90\n minutes.\n\n Region of interest analysis of the tracer activity in the stomach shows 39%\n activity to have emptied during the first hour of imaging. Another 30 minutes\n of imaging revealed an additional 18% emptying. The overall gastric emptying\n half-time is approximately 90 minutes for the study.\n\n IMPRESSION: Slightly delayed gastric emptying with a half-time of approximately\n 90 minutes. /nkg\n\n\n , M.D.\n , M.D. Approved: FRI 2:29 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Nursing/other", "chartdate": "2200-11-23 00:00:00.000", "description": "Report", "row_id": 1299056, "text": "MICU NPN\n S/O: V/S stable. No orthostatic changes. Repeat HCT at 10am 32.3, up from 29. No blood products given. Continues NPO. Up to commode x one with assist of 2, but no stool. Had c/o some cramping. No N/V.\n U/O excellent. Recieving IVF at 150/hr. Got 40 k for k 3.3.\n Has recieved 4mg IV MSO4 q 4 hours for h/a pain. Appears to rest comfortably when not disturbed.\n Mother called from . Advised her of pt's pending transfer to med floor. She will speak to pt later by phone.\n A/P: Stable post GI bleed. NPO til repeat endoscopy tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2200-11-22 00:00:00.000", "description": "Report", "row_id": 1299053, "text": "MICu NSG Admission Note:\n 42 yo admitted from 7F for GI bleed.\n Originally admitted to the hospital on after one week of N/V and Headache. This am several episodes of cofee ground emesis. HCT 37.\nGiven NS and antiemetics. Transferred to MICU at 1pm.\n\n PMH: Reflex sympathy dystrophy: R lower arm amputation; Osteopenia; GI bleed; Hirschsprings; GERD; ETOH abuse; HSV; Numerous podiatric procedures; urinary retention.\n\n Allergies: >30 medications as noted in MD's note.\n\n ROS: GI: Vomitted enroute, while off constant suction. Total of > 300cc ot coffee ground emesis. Denies abd pain. Belly firm and with bowel sounds. NPO. Repeat HCT after fluid resus: 33.5. No Blood products ordered as yet.\n GU: Hadn't voided all shift, so Foley place upon arrival with about 500cc dark yellow urine out. BUN/Cr WNL.\n Respiratory: RR 6-12. Lungs coarse. ? Aspiration during episodes of vomitting this am. Afebrile. Expectorated very thick whitish sputum sent for culture. On 4l NC with sats in upper 90's. Had been 93 on RA.\n Cardiac: BP 90-110/60. Pulse 80-90 NSR. Baseline low Bp reportedly.\nReceiving NS at 125cc/hr.\n Lines: CXR shows good placement of Cordis, so line now in use.\n3 peripheral lines in place.\n Neuro: Sleepy but easily aroused and oriented. Following commands.\n Social: Pt not very forthcoming when asked about family. States they are out of state. No calls received from family/friends.\n : For endoscopy. Blood products as ordered. NPO except for meds.\n" }, { "category": "Nursing/other", "chartdate": "2200-11-22 00:00:00.000", "description": "Report", "row_id": 1299054, "text": "Brief procedure note/nursing progress note:\nPt tolerated endoscopy with total of 2mg IV versed for sedation. Lots of coffee grounds were seen in the fundus of the stomach which was sucked out. EGD revealed gastritis with several non-actively bleeding tears. GI recommends for her to have repeat scope in 48hrs. Pt is to be NPO. IVF wide open during the procedure but now at 150cc/hr. Started on reglan and zantac IV. Hold PO meds for now and use IV morphine for pain as needed until she wakes up or is not GI bleeding. Pt is to have hct drawn at 7PM and has had a request for two units PRBC's to be set up for her in the blood bank. Last hct was down to 33 at 3PM. MD relayed finding of the EGD to pt and got consent for the blood products if needed to be transfused tonight.\n" }, { "category": "Nursing/other", "chartdate": "2200-11-23 00:00:00.000", "description": "Report", "row_id": 1299055, "text": "P-MICU NPN 7p-7a\nSystem Review:\n\nGI: +BS, +flattus c/o nausea several times w/out vomitting Abdomen soft, no tenderness. Serial Hcts drawn at 9p, 1a, and 6a (31.6/31.8/pend). No s/sx of active bleed at present.\n\nGU: Foley cath intact.\n\nCV: BP has been stable in the high 90's-100's. HR 90's SR no ectopy.\n\nPain Control: C/O pain several times, primarily having a headache. Received MSO4 4mg times 3 over night with good effect. Also received one dose of zofran times one. Lido patched obtained and placed on pts feet ~11pm.\n\nLines: Periperal lines intact. Cordis also intact, +blood draws and infusing without difficulties.\n\nSocial: Pt given phone, and has made several phone calls to family, informing them of being in the ICU. Cell phone at bedside also, but pt has been informed not to use it in this unit.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2105-04-01 00:00:00.000", "description": "Report", "row_id": 1576814, "text": "Nursing Progress Note\n\nPlease see Carevue and MARS for further details of care.\n\nNEURO: Pt A&O x's 3. , , equal strength bilaterally. No neuro deficits noticed at this time.\n\nCV: HR A-fib, rate=70-120, no ectopy. Tmax 99.4f orally. All pulses palpable, pt is warm and well-perfused. Levo gtt turned off at 0900, MAP's have been > 70mmHg since. A-line d/c'd this afternoon.\n\nRESP: Pt on 2liters NC, SaO2 > 94% all shift. Lung sounds clear through upper lobes, diminished over bases, with some crackles heard in the bases. No resp distress, strong productive cough present. Sputum culture sent this afternoon.\n\nGI/GU: Active bowel sounds, pt taking thickened liquids without difficulty. Pt had 3 soft BM's today, guiac negative, specimen sent for C.Diff. Foley to gravity, urine output has been 40-70cc/hr.\n\nSkin intact, turning q2hrs. Pt has central access, a TLC in R Subclavian. Pt has been c/o left heel pain possibly from shoes, tylenol given unsuccessfully, 5mg oxycodone just given , monitor effects.\n" }, { "category": "Nursing/other", "chartdate": "2105-04-02 00:00:00.000", "description": "Report", "row_id": 1576815, "text": "alert and oriented x3. mae to command. denied pain.\ncv afib bp stable. cvp single # to higher #. Pt. awoke wheezy as well.stat neb given and responded slightly well. sats down and cvp up. M.D. in to evaluate. 20ivp lasix given and is responding well.\nfoley noted to be leaking once. ? source.\noozing sm amts stool. turned and completly bathed. incont. cream to rectal area which is a bit chafed and sore.\nskin intact am labs pending. has begun to diurese from lasix\no2 70 % face mask added until lasix works. Sats have improved with extra o2. Drinking water throughout the night in gulps. Encouraged to slow down.\n\n" }, { "category": "Nursing/other", "chartdate": "2105-04-02 00:00:00.000", "description": "Report", "row_id": 1576816, "text": "Nursing Progress Note:\n\nPlease see Carevue and MARs for further details of pt care.\n\nNEURO: Pt A&O x's 3, dozing at times, PEARL, . No neurological deficits noticed at this time. Pt sometimes states inappropriate things such as, \"i need to go back to bed\" although she remains oriented to place, time,etc. This is baseline according to family.\n\nCV: Pt febrile this morning, HR up to the 130's-140's, in A-fib. Pt loaded with .25mg Digoxin IV. HR down to 70's, BP unable to compensate, dropping to 70's systolic. Two fluid boluses given without affect, pt started on Levophed. Pt currently on .03mcg/kg/min of Levophed, have weaned as BP will tolerate. Another 500cc bolus given recently for volume. CVP has been . Pt remains in A-fib at a controlled rate. SBP now in the low 100's. Tmax 100.6f oral, Tulenol given.\n\nRESP: Pt was on 70% face mask this morning with crackles in the bases, able to wean down to 2L NC. Pt has exp wheeze at times, receiving alb. nebs q6hrs. Pt has productive cough, receiving chest PT with very good effect. SaO2 has remained>94%. No resp distress seen.\n\nGI/GU: Active BS, one small BM today. Pt eating pureed foods, thickened liquids. Foley to gravity, urine output has been 50-70cc/hr, clear yellow.\n\nPt has no skin breakdown at this time. Left heel reddened and soar, elevating on pillow, boot ordered. Turning pt q2hrs. Pt has TLC in subclavian, one PIV Left AC.\n" }, { "category": "Nursing/other", "chartdate": "2105-04-01 00:00:00.000", "description": "Report", "row_id": 1576813, "text": "npn\nneuro pleasant woman. aox2 dozing lightly thru shift.\ncad hr afib 117 to 84. b/p remains on levophed gtt decreased to .03mcg/kg with map on aline 60-70's uo >30cc/hr.\nresp remains on 2l nc with sats mid 90's ls clear with dim. bases. periodic non-prod. coughing.\ngi: bs+ no bm no flatus noted\ngu: pt received approx. 2500 to 3000 cc in ew during sepis protocol initiation. uo 35cc/hr approx. urine sent for analysis.\nid pt off sepsis protocol with svo2 68 nto 73 lactate 1.2 from 2.2. current temp 97.5 oral.\nplan\" cont to moniotr vs and labs, titrate levo to maintain map >60 and cont. urine oupput.\n\n" }, { "category": "Nursing/other", "chartdate": "2105-04-03 00:00:00.000", "description": "Report", "row_id": 1576817, "text": "MICU NPN:\nNEURO: Alert to person, place and states correct date but states year \".\" Appropriate responses to questions with occasional confusion but easily reorients i.e. \"I can't seem to urinate\" when pt. has catheter. Denies pain. MAE x4. PERL.\nCV: Afeb. HR 90s-100s AF with occasional PACs. Levophed weaned off last pm but hypotensive this am s/p 1L NS boluses without much effect and levo restarted this am at 0.02mcg/kg/min to maintain MAP >60. Skin warm and dry with palpable pedal pulses bilat. CVP 8-10. R SC TLC line intact with grey port occluded and unable to flush.\nRESP: Wearing 2L O2 via NC with O2 Sat >94%. LS coarse throughout with intermittent expiratory wheezes- nebs q6hrs with good effect. Chest PT given to loosen secretions. Coughing up light tan secretions in moderate amts. Using Yankaar to sxn away.\nGU/GU: Abd. soft, slightly distended with positive bowel sounds. Loose BMs x2 with C-diff sample sent. Stool heme negative. Taking in pureed foods with thickened liquids and aspiration precautions. Foley with clear yellow urine >50cc/hr.\nSKIN: L heel red but no open areas. Peri-area excoriated with anti-fungal cream applied. Repositioned side to side. L peripheral IV intact. In for PICC line eval.\n" }, { "category": "Nursing/other", "chartdate": "2105-04-03 00:00:00.000", "description": "Report", "row_id": 1576818, "text": "Resp Care\n\nPt stable on 2l naslal cannula with sats in mid 90's. Bs coarse with scatter wheezes. Receiving alb/atr q4-6.\n" }, { "category": "Nursing/other", "chartdate": "2105-04-03 00:00:00.000", "description": "Report", "row_id": 1576819, "text": "FINARSD 4 ICU NPN 0700-1900\n\nAlert OX3. MAE. OOB to chair X2 hrs. Able to take few steps to chair. Tol well.\n\nSats low to mid 90's on 2L NP. Desat to low 80's on RA. Good cough. Productive thick, yellow secretions. Using yankauer suction. BS coarse with crackles at bases. Occas exp wheezes. Receiving nebs from RT.\n\nRemains in AF. HR 90-'s to low 100's No VEA noted. Levo weaned & d/c'd. SBP 100's-120's. C-echo done. Results pnd.\n\nT-max 99 PO. Vanco trough 11. Dosing changed to Qd from QOD. On pipercillin. BC X2 (X1 from presept cath, X1 peripheral stick). Stool for c-diff sent\n\nAppitite fair to good. Tol sips water with meds. Taking liquids with thickit. Several small to mod loose brown stools.\n\nButtocks excoriated. Aquafor cream applied.\n\nUO ~50 cc hr. Positive fld balance 600 cc's.\n\nGrandchildren visited.\n\nA/P: Stable off pressors.\n O2 to maintain sats >90. Encourage TC&DB\n" }, { "category": "Nursing/other", "chartdate": "2105-04-04 00:00:00.000", "description": "Report", "row_id": 1576820, "text": "MICU NPN:\nNEURO: A&Ox3. Pleasant and cooperative. MAEWx4. Denies pain. PERL.\nCV: Afeb. HR 80s-100s AF with occ. PACs. BP stable with MAPs>60 although BP lowers with sleeping- easily arousable. Skin warm and dry with palpable pedal pulses bilat. Trace edema. Cardiac echo done yesterday with results pending.\nRESP: Continues on 2L O2 with O2 Sat >93%. LS coarse with crackles at bases and occasional expiratory wheezes resoving with nebs. Productive cough of yellowish sputum in moderate amts- using Yankaar to sxn away.\nGI/GU: Abd. soft, slightly distended with positive bowel sounds. No BM overnight. Colace held due to recent loose BMs (C-diff samples sent). Tolerating pureed foods with thickenend liquids and also taking pills with sips H2O without difficulty- Aspiration precautions maintained. Foley with clear yellow urine >40cc/hr.\nSKIN: Intact. R TLC line intact with grey port occluded. Peripheral IV to L forearm intact.\n\n" }, { "category": "Echo", "chartdate": "2105-04-03 00:00:00.000", "description": "Report", "row_id": 63067, "text": "PATIENT/TEST INFORMATION:\nIndication: AVR Endocarditis.? Left ventricular function.\nHeight: (in) 66\nWeight (lb): 140\nBSA (m2): 1.72 m2\nBP (mm Hg): 127/70\nStatus: Inpatient\nDate/Time: at 15:47\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is mildly dilated. The ascending aorta is moderately\ndilated.\n\nAORTIC VALVE: A bioprosthetic aortic valve prosthesis is present. The\ntransaortic gradient is normal for this prosthesis. Trace aortic regurgitation\nis seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. Mild to moderate (+) mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a high risk (prophylaxis strongly recommended).\nClinical decisions regarding the need for prophylaxis should be based on\nclinical and echocardiographic data.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated. The\nascending aorta is moderately dilated. A bioprosthetic aortic valve prosthesis\nis present. The transaortic gradient is normal for this prosthesis. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild to moderate (+) mitral regurgitation is seen. Moderate [2+] tricuspid\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nCompared with the findings of the prior study (tape reviewed) of ,\nmitral regurgitation and tricuspid regurgitation are now more prominent.\nEstimated pulmonary artery systolic pressure is now higher. The previously\nnoted echodensity in the left atrium is not seen in this study.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a high risk (prophylaxis strongly recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nIMPRESSION: No vegetation identified but cannot exclude.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-31 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 821414, "text": " 11:29 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: ? sinusitis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman re-admitted w/sepsis: febrile to 103, bandemia, hypotensive\n on pressors. Just d/c'd 5 days ago s/p urosepsis ICU stay. No focal findings\n on exam today, but nasal discharge and lots of sputum production.\n\n REASON FOR THIS EXAMINATION:\n ? sinusitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: VK WED 12:52 AM\n No sinusitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87 y/o with fevers and nasal discharge/sputum, question\n sinusitis.\n\n TECHNIQUE: Axial non-contrast images of the paranasal sinuses. Reformatted\n images in the sagittal and coronal planes were performed.\n\n SINUS CT: The paranasal sinuses are normally aerated with no mucosal\n thickening or air fluid levels identified, other than a minimal degree of\n mucosal thickening just anterior to the left maxillary sinus ostium. The\n ostiomeatal units are patent. There is bilateral bullosa, left greater\n than right. The lamina papyracea are intact. Nasal septum is slightly deviated\n to the right. The osseous structures are unremarkable.\n\n IMPRESSION: No overt sinusitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-31 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 821415, "text": " 11:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: ? perinephric abscess\n Admitting Diagnosis: SEPSIS\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with recent d/c from s/p urosepsis and micu stay, returns\n 5 days post d/c with septic physiology, on pressors, no focal source but\n bandemia, febrile. ? perinephric abscess.\n REASON FOR THIS EXAMINATION:\n ? perinephric abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: VK WED 12:51 AM\n No perinephric abscess. Cholelithiasis. diverticulosis. Left atrial\n hypodensity, likely myxoma given pt's prior hx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 87-year-old with recent urosepsis, now septic again, assess\n for perinephric abscess.\n\n CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST: Contiguous axial images from\n the lung bases to the pubic symphysis. Optiray was used due to patient's\n history of debility.\n\n Comparison is made to .\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There are small bilateral pleural\n effusions with associated atelectatic changes at the lung bases. No lung\n nodules are noted. The heart is slightly enlarged. Within the left atrium\n there is a 1.4 x 1.5 cm hypodensity. The liver, spleen, pancreas, and\n adrenals are unremarkable. There are small gallstones within the gallbladder.\n The gallbladder is otherwise normal. There are multiple cysts throughout\n both the right and left kidney. There is a small amount of stranding of the\n fat posterior to the right kidney. No cortical hypodensities are seen in\n either kidney to suggest pyelonephritis or infarction. No perinephric\n fluid collections seen surrounding either kidney. The intra-abdominal\n vessels and large and small bowel are normal. There is no free fluid, free\n air, or pathologic lymphadenopathy within the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: There are numerous diverticula within the\n sigmoid colon with fecaliths within the diverticula. The rectum and visualized\n bladder are normal in appearance. There is marked streak artifact throughout\n the pelvis due to a right hip prosthesis limiting evaluation of the pelvis.\n There does not appear to be any free fluid or lymphadenopathy within the\n pelvis.\n\n Bone windows revealeft no suspicious lytic or blastic lesions. A right hip\n prosthesis is present.\n\n IMPRESSION:\n (Over)\n\n 11:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: ? perinephric abscess\n Admitting Diagnosis: SEPSIS\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. No perinephric abscess. Minimal amount of stranding around the right\n kidney present. No cortical hypodensities to suggest pyelonephritis or\n infarction.\n 2. Hypodensity within the left atrium. Given the patient's prior history of\n a myxoma, this likely represents the myxoma. Thrombus would have the same\n appearance.\n 3. Cholelithiasis without cholecystitis.\n 4. Diverticulosis without diverticulitis.\n\n\n These findings were communicated to the house staff taking care of the\n patient.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2105-04-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821679, "text": " 11:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? evolving pna\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with urosepsis with aggressive iv hydration now with\n crackles, s/p pulling back right IJ line. Please assess new placement.\n\n REASON FOR THIS EXAMINATION:\n ? evolving pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 87-year-old woman with urosepsis after aggressive hydration.\n\n AP SEMI-ERECT SINGLE VIEW OF THE CHEST is compared to a simlar view from , .\n\n FINDINGS: The patient is status post median sternotomy, CABG and aortic valve\n replacement. The aorta is unfolded and calcified. The cardiac, mediastinal\n and hilar contours are unchanged in appearance. There is upper zone\n redistribution of the pulmonary artery vasculature and perihilar haziness\n consistent with pulmonary edema due to CHF. This is unchanged when compared\n to the previous study. Small bilateral pleural effusions. There is a right\n IJ central line with the tip in the lower SVC.\n\n IMPRESSION:\n 1. Small lung volumes.\n 2. Continued pulmonary edema due to CHF.\n\n" }, { "category": "Radiology", "chartdate": "2105-04-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 821878, "text": " 9:05 AM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for infiltrate, effusion, pulmonary edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with hx CHF and asp PNA.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate, effusion, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of CHF and aspiration pneumonia. Evaluate for\n infiltrate, effusion, pulmonary edema.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: The patient is status post median sternotomy and mitral\n valve replacement. Cardiomegaly is again noted. The extent of pulmonary\n edema has improved in the interval. There are bibasilar opacities, which may\n be secondary to pulmonary edema, although aspiration in these locations cannot\n be excluded. There are small bilateral pleural effusions. Again noted is an\n old compression fracture of the lower thoracic spine.\n\n The right-sided central venous catheter appears to be kinked at the skin\n surface.\n\n IMPRESSION:\n 1. Improving pulmonary edema. Opacities at the lung bases may relate to\n pulmonary edema, although aspiration cannot be excluded.\n 2. Bilateral pleural effusions.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821410, "text": " 9:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p right ij placement, pls eval for pneumo, line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with urosepsis with aggressive iv hydration now with\n crackles, s/p pulling back right IJ line. Please assess new placement.\n\n REASON FOR THIS EXAMINATION:\n s/p right ij placement, pls eval for pneumo, line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess central venous catheter placement.\n\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH\n\n COMPARISON: Made to study three hours prior.\n\n The cardiac and mediastinal contours and lung fields are all changed in\n appearance. A right IJ central venous catheter is seen with its tip in the\n lower portion of the right atrium. There is no pneumothorax.\n\n IMPRESSION: Unchanged appearance of the lungs. Malpositioned central venous\n catheter. These could be pulled back approximately 7 cm.\n\n These findings were communicated to Dr. \n\n" }, { "category": "Radiology", "chartdate": "2105-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821413, "text": " 10:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: right ij pulled back, pls eval positiion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with urosepsis with aggressive iv hydration now with\n crackles, s/p pulling back right IJ line. Please assess new placement.\n\n REASON FOR THIS EXAMINATION:\n right ij pulled back, pls eval positiion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess line position.\n\n Comparison is made to 2 studies of earlier the same day.\n\n The right IJ line has been withdrawn and now terminates in the distal SVC.\n There has been no other change in the appearance of the chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2105-04-06 00:00:00.000", "description": "PICC W/O PORT", "row_id": 821895, "text": " 12:47 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC placement under IR guidance for antibiotic\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with aspiration pneumonia and sepsis.\n REASON FOR THIS EXAMINATION:\n Please place PICC placement under IR guidance for antibiotic therapy; unable to\n place at bedside\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aspiration pneumonia and sepsis. IV unable to place PICC at\n bedside.\n\n PROCEDURE/TECHNIQUE: The procedure was performed by Drs. and \n with Dr. , the attending physician present and\n supervising. The patient's right upper arm was prepped and draped in a\n standard sterile fashion. After local anesthesia with 1% lidocaine was\n applied, the right brachial vein was entered with a 21 gauge needle under\n ultrasonographic guidance. A 0.018 gidewire was advanced into the superior\n vena cava using fluoroscopic guidance. Based upon the markers and the\n guidewire, it was determined that a length of 35 cm would be appropriate. The\n single lumen PICC was then cut to this length. The PICC line was advanced\n over a 4 French introducer sheath using fluoroscopic guidance. The wire and\n sheath were removed. A final chest x- ray showed the PICC tip in the distal\n SVC above the right atrium. The line was flushed and heplocked. The line was\n secured with a statlock. The patient tolerated the procedure well with no\n post procedure complications.\n\n IMPRESSION:\n\n Successful placement of a right sided 35 cm total length single lumen PICC\n with tip in the distal SVC. The line is ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2105-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821405, "text": " 6:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneu\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with urosepsis with aggressive iv hydration now with\n crackles, s/p pulling back right IJ line. Please assess new placement.\n\n REASON FOR THIS EXAMINATION:\n r/o pneu\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Urosepsis. Question of pneumonia.\n\n COMPARISON: .\n\n FINDINGS: AP upright view. The right internal jugular venous catheter has been\n removed. There is interval resolution of pulmonary edema and pleural\n effusions. There is a patchy opacity in the left lower lobe, which may\n represent pneumonia. Sternotomy wires and surgical clips are again noted in\n the mediastinum.\n\n IMPRESSION:\n\n 1) Left lower lobe patchy opacity, consistent with pneumonia.\n 2) Interval resolution of pulmonary edema and pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2105-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821437, "text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?line placement, evidence of pna/aspiration\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with urosepsis with aggressive iv hydration now with\n crackles, s/p pulling back right IJ line. Please assess new placement.\n\n REASON FOR THIS EXAMINATION:\n ?line placement, evidence of pna/aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old female with urosepsis. Now rule out CHF or pneumonia.\n\n COMPARISON: .\n\n FINDINGS: AP semiupright single view of the chest. Patient is status post CABG\n and aortic valve replacement through a medial sternotomy. There is\n calcification and unfolding of the aorta. There is slight cardiomegaly, due\n primarily to ventricular enlargement. There is mild upper zone redistribution\n of the pulmonary artery vasculature. These findings are consistent with mild\n CHF. In the interval when compared to the previous there is a slight worsening\n of the CHF.\n\n IMPRESSION: Cardiomegaly with mild CHF.\n\n" }, { "category": "ECG", "chartdate": "2105-03-31 00:00:00.000", "description": "Report", "row_id": 119007, "text": "Atrial fibrillation with a rapid ventricular response. ST segment depression\nand T wave inversion in leads V5-V6. ST segment depression and low amplitude\nT waves in lead V4. Compared to the previous tracing of to the previous\ntracing of the rate has increased. ST segments have decreased in the\nstated leads. T waves were uniformly of low amplitude.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2136-10-15 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1216598, "text": " 10:48 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? PTX after RT CT removed. Upright\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with CABG\n REASON FOR THIS EXAMINATION:\n ? PTX after RT CT removed. Upright\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Portable supine radiographic view of chest was compared with prior\n studies through to .\n\n FINDINGS:\n\n Since prior radiograph from acquired few hours apart, the\n right chest tube has been removed. No evidence of pneumothorax. Left PICC\n line ends at cavoatrial junction and orogastric tube is seen to course below\n the diaphragm ending into the stomach, all appropriately positioned. Status\n post median sternotomy and has intact sternal sutures. Moderate-to-large left\n pleural effusion has increased since . Increased\n retrocardiac density suggests left lower lung atelectasis. Pleural effusion,\n if any, is minimal on the right side. No lung opacities on the right side\n concerning for pneumonia. Top normal heart size, mediastinal and hilar\n contours are stable in appearance.\n\n IMPRESSION: Moderate-to-large left pleural effusion associated with left\n lower lung atelectasis has increased since . In the setting\n of recent CABG and increasing effusion, hemorrhagic pleural effusion cannot be\n ruled out.\n\n Findings were discussed with Dr. on at 12:41\n p.m.\n\n" }, { "category": "Radiology", "chartdate": "2136-10-10 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1216007, "text": " 3:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval loction of dobhoff\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with placement of dobhoff\n REASON FOR THIS EXAMINATION:\n eval loction of dobhoff\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:22 PM\n The tip of the new Dobhoff feeding tube resides within the duodenum.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate location of Dobhoff feeding tube.\n\n COMPARISON: Chest radiograph from at 10:19 a.m.\n\n PORTABLE SUPINE RADIOGRAPH OF THE CHEST: The new Dobhoff tube can be seen\n passing through the stomach with the tip residing within the duodenum. The\n remainder of the examination is unchanged from the prior study.\n\n IMPRESSION: The tip of the new Dobhoff feeding tube resides within the\n duodenum.\n\n" }, { "category": "Radiology", "chartdate": "2136-10-10 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1216008, "text": ", CSURG CSRU 3:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval loction of dobhoff\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with placement of dobhoff\n REASON FOR THIS EXAMINATION:\n eval loction of dobhoff\n ______________________________________________________________________________\n PFI REPORT\n The tip of the new Dobhoff feeding tube resides within the duodenum.\n\n" }, { "category": "Echo", "chartdate": "2136-09-28 00:00:00.000", "description": "Report", "row_id": 95598, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion.\nHeight: (in) 72\nWeight (lb): 166\nBSA (m2): 1.97 m2\nBP (mm Hg): 122/79\nHR (bpm): 99\nStatus: Inpatient\nDate/Time: at 10:49\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Significant AS is present (not quantified)\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Calcified tips of papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Very small pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). The right ventricular cavity is mildly dilated with mild global\nfree wall hypokinesis. The diameters of aorta at the sinus, ascending and arch\nlevels are normal. Significant aortic stenosis is present (not quantified).\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined. There is a very small pericardial\neffusion.\n\nIMPRESSION: Symmetric LVH with normal global and regional biventricular\nsystolic function. Mild mitral regurgitation. Aortic stenosis (not quantified)\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "Echo", "chartdate": "2136-09-25 00:00:00.000", "description": "Report", "row_id": 95599, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. S/p CABG\nHeight: (in) 72\nWeight (lb): 166\nBSA (m2): 1.97 m2\nBP (mm Hg): 104/40\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 10:17\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter\n(<=2.1cm) with >50% decrease with sniff (estimated RA pressure (0-5 mmHg).\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Overall normal\nLVEF (>55%). Transmitral Doppler E>A and TDI E/e' <8 suggesting normal\ndiastolic function, and normal LV filling pressure (PCWP<12mmHg). No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. RV function depressed.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Borderline PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Very small pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The estimated right atrial pressure is\n0-5 mmHg. There is moderate symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal\ndiastolic function, and a normal left ventricular filling pressure\n(PCWP<12mmHg). Right ventricular chamber size is normal. with depressed free\nwall contractility. The aortic valve leaflets are moderately thickened. There\nis mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is borderline pulmonary artery systolic hypertension. There is a very\nsmall pericardial effusion.\n\nThere is an approximately 0.5 cm diameter mobile echodense structure in the\nright ventricle adjacent to the trabeculae/chordae which may represent a loose\nchord; cannot exclude a mass/thrombus.\n\nCompared with the prior study (images reviewed) of , the heart rate\nis now higher and atrial fibrillation is now present and there is evidence of\nelevated PCWP in the current study. The small echodense structure in the right\nventricle appears to be new.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-09-28 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 1214490, "text": " 6:54 PM\n RENAL U.S.; DUPLEX DOPP ABD/PEL Clip # \n Reason: eval for stenosis/flow - please do with doppler\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man rising BUN/Crea\n REASON FOR THIS EXAMINATION:\n eval for stenosis/flow - please do with doppler\n ______________________________________________________________________________\n WET READ: JKSd FRI 7:22 PM\n Large left pleural effusion.\n\n Limited doppler evaluation as patient cannot hold breath.\n\n Resistive indices up to 0.82 on right and 0.86 on left. Main renal arteries\n and veins are patent.\n\n No hydronephrosis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old man with rising BUN/creatinine. Evaluate for\n stenosis.\n\n COMPARISON: Renal ultrasound .\n\n FINDINGS: The right kidney measures 7.9 cm. Punctate echogenic foci near the\n periphery may represent tiny non-shadowing stones or vascular calcifications.\n There is no hydronephrosis. The main renal vein and artery are patent.\n Resistive indices of the right kidney range from 0.80 to 0.82.\n\n The left kidney measures 8.1 cm. A small renal cyst is noted in the upper\n pole of the left kidney. There is no hydronephrosis. The main renal vein and\n artery are also patent. Resistive indices of the left kidney range from 0.82\n to 0.86.\n\n Note is made of a large left-sided pleural effusion.\n\n IMPRESSION:\n 1. Suboptimal Doppler evaluation as the patient could not hold his breath.\n 2. Main renal arteries and veins are patent bilaterally. Resistive indices\n range up to 0.82 on the right and 0.86 on the left. No hydronephrosis.\n 3. Large left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2136-09-29 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1214592, "text": " 11:40 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ett tube and central line placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n M s/p 6 vessel CABG, NOW s/p TAC for C diff colitis.\n REASON FOR THIS EXAMINATION:\n ett tube and central line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST FILM, AT 22:31\n\n CLINICAL INDICATION: -year-old status post CABG, now with C. diff colitis,\n check placement of endotracheal tube and central line.\n\n Comparison is made to the patient's previous study of at 11:13.\n\n Single portable supine chest film dated at 22:31 is submitted.\n\n IMPRESSION:\n\n 1. Right subclavian central line with its tip in the superior vena cava.\n Interval intubation with the tip of the endotracheal 2 cm above the carina.\n Interval placement of a nasogastric tube coursing below the diaphragm with the\n tip not identified on the current study.\n\n 2. Diffuse bilateral haziness likely representing increasing bilateral\n layering pleural effusions. Interval improvement in the mild-to-moderate\n pulmonary edema with no significant pulmonary edema evident at this time. No\n definite focal airspace consolidation can be appreciated. Overall, cardiac\n and mediastinal contours are stable in this postoperative patient status post\n CABG and median sternotomy.\n\n" }, { "category": "Radiology", "chartdate": "2136-10-01 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1214819, "text": " 10:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ex lap-check ETT placement/NGT placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p ex lap-check ETT placement/NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tube placement.\n\n FINDINGS: In comparison with the study of earlier in this date, the\n endotracheal tube tip lies approximately 3.7 cm above the carina. Nasogastric\n tube has been pushed forward so that the side hole is well below the\n esophagogastric junction. Right chest tube remains in place with no evidence\n of pneumothorax. Right subclavian line is unchanged.\n\n Little change or possibly slight improvement in the pulmonary vascular\n congestion in this patient with intact midline sternal wires.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-09-30 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1214641, "text": " 2:47 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for pneumothorax s/p chest tube placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p CABG/colectomy\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP SUPINE CHEST FILM AT 1444\n\n CLINICAL INDICATION: -year-old status post CABG and colectomy, evaluate\n pneumothorax status post chest tube placement.\n\n Comparison is made to the patient's prior study of at 849.\n\n A single portable AP supine chest film dated at 1444 is submitted.\n\n IMPRESSION:\n\n 1. Interval placement of a right chest tube with the tip at the apex of the\n pleural cavity and interval decrease in size of a layering right pleural\n effusion. No large pneumothorax is appreciated, although the study was\n performed with supine technique which limits evaluation. Layering left\n effusion unchanged. More focal retrocardiac consolidation which most likely\n represents compressive atelectasis, though pneumonia in this area cannot be\n excluded. The right lung appears grossly clear. Overall cardiac and\n mediastinal contours are stable in this post-operative patient status post\n median sternotomy for CABG.\n\n 2. Right subclavian central line with its tip in the SVC. Nasogastric tube\n coursing below the diaphragm with the tip not identified. Endotracheal tube\n has its tip 4.5 cm above the carina.\n\n" }, { "category": "Radiology", "chartdate": "2136-09-30 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1214651, "text": " 4:14 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for pneumothorax s/p Left chest tube insertion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p CABG/colectomy\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p Left chest tube insertion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM SEMI-ERECT DATED AT 16:15\n\n CLINICAL INDICATION: -year-old status post CABG and colectomy, status post\n left chest tube placement for effusion, question pneumothorax.\n\n Comparison is made to the patient's previous study at 14:44.\n\n Single portable AP semi-erect chest at 16:15 is submitted.\n\n IMPRESSION:\n\n 1. Stable cardiac and mediastinal contours status post median sternotomy for\n CABG. Right subclavian central line, endotracheal tube, nasogastric tube and\n right chest tube are unchanged in position. Interval placement of a left\n chest tube with decrease in the left pleural effusion. Interval improvement\n in aeration within both lungs with scattered residual linear opacities likely\n reflecting subsegmental atelectasis. No evidence of pulmonary edema. No\n pneumothorax is appreciated.\n\n" }, { "category": "ECG", "chartdate": "2136-10-03 00:00:00.000", "description": "Report", "row_id": 251709, "text": "Atrial flutter. Complete right bundle-branch block. Abnormal tracing.\nCompared to the previous tracing of atrial flutter is new and right\nbundle-branch block persists.\n\n" }, { "category": "ECG", "chartdate": "2136-10-01 00:00:00.000", "description": "Report", "row_id": 251710, "text": "Sinus bradycardia. Borderline prolonged P-R interval. Diffusely low\nQRS voltage. Right bundle-branch block. Compared to the previous tracing\nof the rate is slower and QRS voltage is decreased. Clinical\ncorrelation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2136-09-30 00:00:00.000", "description": "Report", "row_id": 251711, "text": "Baseline artifact. Probable sinus rhythm. Right bundle-branch block.\nGeneralized low QRS voltages. Non-specific ST-T wave abnormalities. Compared to\nthe previous tracing of probable normal sinus rhythm is new.\nGeneralized low QRS voltage is also new and non-specific ST-T wave\nabnormalities are slightly less marked. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2136-09-25 00:00:00.000", "description": "Report", "row_id": 251712, "text": "Atrial fibrillation with controlled ventricular response. Right bundle-branch\nblock. Compared to the previous tracing of atrial fibrillation is now\nrecorded.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2136-09-24 00:00:00.000", "description": "Report", "row_id": 251713, "text": "Sinus bradycardia. Left atrial abnormality. Right bundle-branch block.\nCompared to the previous tracing of the rate has slowed. The\natrial morphology has changed. The P-R interval is slightly shorter.\nOtherwise, no diagnostic interim change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2190-12-07 00:00:00.000", "description": "Report", "row_id": 1455379, "text": "FOCUS: STATUS UPDATE\nNEURO: ALERT AND ORIENTED X3 MAE ON COMMAND, MILDLY ANXIOUS. NO APPARENT NEURO ISSUES.\n\nCV: NSR/RBBB. NORMOTENSIVE. CVP 3 TO 7. NO EXTRA FLUID OVERNOC. PULSES PALPABLE. SKIN WARM AND DRY. CAP REFILL <3SEC. GENERALIZED EDEMA.\n\nRESP: EXTUBATED, WEANED OFF OF O2. SATS 06 TO 100. ENCOURAGED TO COUGH AND DB. LUNG SOUNDS CLEAR.\n\nGI: ABD SOFT MILDLY DISTENDED C/ HYPOACTIVE BOWEL SOUNDS. ABD NON TENDER TO PALPATION. SMALL AMOUNT OF EMESIS PRIOR TO EXTUBATION MEDICATED TO AVOID FURTHER NAUSEA.\n\nGU: FOLEY CATH IN SITU, DRAINING MODERATE AMOUNTS OF CLEAR YELLOW URINE.\n\nENDO: RISS.\n\nPAIN: PO AND IV MEDICATED C. GOOD CONTROL OF PAIN.\n\nPLAN: D/C TO 2. INCREASE ACTIVITY AS TOLERATED. START PO INTAKE.? DIET CONSULT.\n" }, { "category": "Nursing/other", "chartdate": "2190-12-06 00:00:00.000", "description": "Report", "row_id": 1455378, "text": "POST OP ASD REPAIR\n\nNEURO: SEDATED ON PROPOFOL. PEARL. REVERSALS GIVEN. PROP OFF. MSO4 2MG GIVEN.\n\nCARDIAC: NSR. HR 60'S. SBB 110-120. NTG WEANED TO OFF. K+ REPLEATED. CT DRAINAGE MINIMAL. +PP BILATERALLY.\n\nRESP: LUNGS CLEAR. CONT ON SIMV. FIO2 DECREASED TO 50%. SEE FLOW SHEET. SAT'S 100%.\n\nGI/GU: ABSENT BS. ABD SOFT. UOP ADEQUATE.\n\nENDO: BS<125. NO SSRI GIVEN PER PROTOCOL.\n\nSOCIAL: BROTHER INTO VISIT. UPDATE GIVEN. BROTHER TO TRANSLATE IF NEEDED.\n\nPLAN: MONITOR NEURO STATUS, HEMODYNAMICS, HR/RYTHUM, LABS, CT'S. CONT TO FAST TRACK. PAIN MANAGEMENT.,\n" } ]

[ { "category": "Radiology", "chartdate": "2114-07-08 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 793477, "text": " 7:43 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST\n Reason: r/o dissection\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with MVC\n REASON FOR THIS EXAMINATION:\n r/o dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 44 year old male status post motor vehicle collision.\n Evaluate for aortic injury.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n aortic arch through the bifurcation following the administration of 150 cc of\n Optiray according to the dissection protocol. Multiplanar reformatted images\n were included.\n\n COMPARISON: None.\n\n CTA OF THE CHEST: The aorta is intact without evidence of aortic injury. The\n heart appears normal. Lung fields demonstrate bibasilar atelectatic changes.\n There are no pleural or pericardial effusions.\n\n CTA OF THE ABDOMEN: The aorta and its tributaries are intact without evidence\n of traumatic injury. The liver, gallbladder, spleen, pancreas, kidneys, and\n adrenal glands are normal. The stomach and unopacified loops of small and\n large bowel are unremarkable. No abnormal fluid collections are present\n within the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: Limited views of the pelvis demonstrate\n normal pelvic bowel loops. No abnormal fluid collections are present in the\n visualized upper pelvis.\n\n BONE WINDOWS: There is a comminuted fracture of the superior aspect of the\n left scapula. No other fractures are identified.\n\n CT RECONSTRUCTIONS: Coronal reformatted images confirm the above findings.\n\n IMPRESSION:\n 1. No evidence of aortic injury.\n 2. Comminuted fracture of the superior aspect of the left scapula.\n\n\n" }, { "category": "Radiology", "chartdate": "2114-07-10 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 793675, "text": " 8:10 PM\n C-SPINE FLEX AND EXT ONLY 2 VIEWS; -59 DISTINCT PROCEDURAL SERVICEClip # \n Reason: r/o dislocation.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n r/o dislocation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: History of trauma and neck pain.\n\n CERVICAL SPINE: T1 to C7 are included. No evidence for instability. The\n lateral flexion and extension films stop. There is narrowing of the C5-6 disc\n with associated spurs at this level.\n\n" }, { "category": "Radiology", "chartdate": "2114-07-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 793741, "text": " 3:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: rule out new bleed, after falling out of bed and hitting hea\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p previous intracranial bleed after trauma.\n\n REASON FOR THIS EXAMINATION:\n rule out new bleed, after falling out of bed and hitting head. Please do this\n scan afternoon--------\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post prior trauma, now fall out of bed hitting head.\n Reassess scan.\n\n Comparison is made to the prior examination of .\n\n TECHNIQUE: Noncontrast CT of the head.\n\n FINDINGS: No new intra-axial or extra-axial hemorrhage identified. The\n previously described areas of subarachnoid and possible subdural hemorrhage,\n along with evidence of parenchymal contusion of the right anterior temporal\n lobe are unchanged. Sulci within the right cerebral hemisphere demonstrate\n stable amount of effacement as seen previously. There is no mass or shift of\n normally midline structures. There are no newly identified infarctions.\n\n Bone windows reveal no fractures. Minimal mucosal thickening of the ethmoid\n sinuses and opacification of the right maxillary sinus is unchanged.\n\n IMPRESSION: No change from prior exam of .\n\n" }, { "category": "Radiology", "chartdate": "2114-07-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 793503, "text": " 8:46 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n eval for progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CT HEAD WITHOUT CONTRAST:\n\n INDICATION: 44 year old male with trauma after fall from bike.\n\n There is no prior for comparison.\n\n TECHNIQUE: Noncontrast CT of the head.\n\n FINDINGS: Extra-axial hemorrhage is identified in the right inferior frontal\n and right anterior temporal lobe areas. Hemorrhage is seen within adjacent\n sulci in these areas consistent with subarachnoid blood. However, components\n of the hemorrhages in these areas may also be partially subdural in nature. In\n addition, a component of the hemorrhage in the right anterior temporal region,\n in association with adjacent edema, likely represents intraparenchymal injury\n consistent with contusion, also visible in the right inferior frontal lobe\n region. There is no shift of normally midline structures or hydrocephalus\n identified. Extracranial soft tissue swelling is seen in the left posterior\n parietal region, making the injury possibly contra coup in nature.\n\n No fractures are identified. The right maxillary sinus is completely\n opacified and there is minimal mucosal thickening of the ethmoid sinuses,\n which together presumably relate to prior inflammatory and/or allergic\n disease.\n\n IMPRESSION: Right inferior frontal and right anterior temporal subarachnoid\n and possibly subdural hemorrhage. In addition, appearance in the right\n anterior temporal lobe probable for parenchymal hemorrhagic contusion.\n\n NOTE: The extra-axial collections are up to 1cm in thickness.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2114-07-10 00:00:00.000", "description": "C-SPINE (PORTABLE)", "row_id": 793625, "text": " 10:44 AM\n C-SPINE (PORTABLE) Clip # \n Reason: rule out cervical fracture\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with s/p mvc with cervical tenderness\n REASON FOR THIS EXAMINATION:\n rule out cervical fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle collision and cervical tenderness.\n\n AP & LATERAL CERVICAL SPINE: The study is slightly degraded by patient\n motion. In comparison to the prior study of , the alignment of the\n cervical vertebral bodies remains normal for the visualized region of C1\n through C7. Mild loss of disc height and periarticular anterior osteophytosis\n is seen at C5/6, a finding which is most likely chronic. There is no\n fracture. The visualized lung apices are normal in appearance.\n\n IMPRESSION: No evidence of fracture.\n\n" }, { "category": "Radiology", "chartdate": "2114-07-08 00:00:00.000", "description": "C-SPINE, TRAUMA", "row_id": 793438, "text": " 9:03 AM\n C-SPINE, TRAUMA; T-SPINE Clip # \n L-SPINE (AP & LAT)\n Reason: D\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p MVA\n REASON FOR THIS EXAMINATION:\n Evaluate for evidence of fracture\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post MVA.\n\n AP, lateral, swimmer's and odontoid views of the cervical spine demonstrate no\n evidence of fracture or dislocation. The lateral views visualize the\n vertebral bodies through the superior aspect of T1. The prevertebral soft\n tissues are upper limits of normal anterior to C1-C2. The lateral masses are\n C1 are symmetric about an intact dens. There is intervertebral disc space\n narrowing and osteophytosis at C5/6 consistent with degenerative changes.\n\n AP and lateral views of the thoracic spine demonstrate no evidence of fracture\n or dislocation. The vertebral body height and intervertebral disc spaces are\n normal. Mild osteophytosis is noted in the mid thoracic spine consistent with\n mild degenerative changes.\n\n AP and lateral views of the lumbar spine and pelvis demonstrate no evidence of\n fracture or dislocation. Note is made of overlying artifact on the AP view.\n The vertebral body height and alignment is normal. There is slight loss of\n intervertebral disc space at L3/4 with minimal osteophytosis.\n\n IMPRESSION: No evidence of acute injury to the cervical, thoracic or lumbar\n spine. Mild degenerative changes are noted at C5/6, the mid thoracic spine\n and at L3/4.\n\n\n" }, { "category": "Radiology", "chartdate": "2114-07-08 00:00:00.000", "description": "L HUMERUS (AP & LAT) LEFT", "row_id": 793437, "text": " 9:03 AM\n HUMERUS (AP & LAT) LEFT; FOREARM (AP & LAT) LEFT Clip # \n HAND (AP, LAT & OBLIQUE) LEFT\n Reason: TRANSFERED FORM OSH WITH ? BIKE VS. AUTO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p MVA\n REASON FOR THIS EXAMINATION:\n Evaluate for evidence of fracture\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left upper extremity pain after MVA.\n\n Multiple views of the left upper extremity, including humeral views, AP &\n lateral views of the elbow without and without a cast, and three views of the\n left wrist are provided. There is a left radial head fracture extending from\n the lateral metaphysis to the interarticular surface, and there is a small\n osseous fragment within the joint space in this region. On the lateral view,\n it appears there is a small separate calcific density anterior to the\n coronoid process, which may be corticated (i.e. chronic), although detailed\n evaluation is limited on the views provided. There is a joint effusion. There\n is no abnormality in the humerus or glenohumeral joint. A linear luceny at\n the inferior tip of the scapula is seen on one view, of uncertain\n significance.\n\n Three views of the left hand and wrist are unremarkable.\n\n IMPRESSION: 1. Minimally displaced intra-articular fracture left radial head,\n with associated joint effusion.\n\n 2. See above commetns regarding a separate calcific density anterior to the\n cornoid process of the proximal ulna, and an apparent lucency in the scapula\n inferiorly. Correlation with physical exam is recommended, with additional\n imaging as clinically indicated.\n\n" }, { "category": "Radiology", "chartdate": "2114-07-08 00:00:00.000", "description": "L WRIST(3 + VIEWS) LEFT", "row_id": 793469, "text": " 4:17 PM\n WRIST(3 + VIEWS) LEFT; ELBOW (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: please perform out of splint with wrist in pronation, r/o ra\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p MVA\n REASON FOR THIS EXAMINATION:\n please perform out of splint with wrist in pronation, r/o radial-ulnal joint\n separation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Question radial-ulnar joint separation.\n\n Lateral elbow and AP left wrist status post casting demonstrates normal\n alignment of the bones in the elbow and wrist. Previously described fractures\n within the elbow are obscured by casting material.\n\n" }, { "category": "Radiology", "chartdate": "2114-07-08 00:00:00.000", "description": "CT UP EXT W/O C", "row_id": 793470, "text": " 4:25 PM\n CT UP EXT W/O C; CT RECONSTRUCTION Clip # \n Reason: evaluate fx, s/p reduction- L distal radius/elbow fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with L prox radial head fx p MVC\n REASON FOR THIS EXAMINATION:\n evaluate fx, s/p reduction- L distal radius/elbow fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 44 y/o male with radial head fracture.\n\n COMPARISONS: Radiographs dated .\n\n TECHNIQUE: Thin collimation axial images were performed through the elbow.\n Coronal and sagittal reformats were created and evaluated on the work station.\n\n CT, LEFT ELBOW, WITHOUT CONTRAST: There is an intra-articular fracture of the\n radial head, which extends in a plain perpendicular to the long axis of the\n radius. There is minimal separation of fracture fragments of approximately\n 1-2 mm and minimal step off. There is no evidence of dislocation. No radial\n foreshortening is noted. There is a nondisplaced fracture at the tip of\n coronoid.\n\n Joint hemarthrosis is present. No other acute bony abnormalities are\n identified.\n\n IMPRESSION:\n\n 1. Intra-articular radial head fracture, which is in near anatomic alignment.\n\n 2. Nondisplaced coronoid tip fracture.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2114-07-08 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 793436, "text": " 8:36 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: ON BIKE HIT BY ? AUTO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bike accident, intoxicated.\n\n COMPARISON: None.\n\n FINDINGS: Chest: Allowing for technique, the heart is not enlarged. The\n medistinum is slightly prominent, but this may also be related to technique.\n There is no pulmonary vascular congestion, pleural effusion, focal infiltrate,\n or pneumothorax. No displaced rib fractures are seen.\n\n Pelvis: A Foley catheter is present within the bladder. There is amorphous\n high density material surrounding the left hip joint, which appears to be\n artifactual. No displaced fractures are seen. Hip joints and SI joints are\n within normal limits. Bowel gas pattern is unremarkable.\n\n IMPRESSION:\n\n No overt traumatic abnormality. Pelvis should be repeated due to artifact\n described above.\n\n" }, { "category": "Nursing/other", "chartdate": "2114-07-09 00:00:00.000", "description": "Report", "row_id": 1265638, "text": "T-SICU Nsg Note\n Somnolent most of day. Brief periods of agitation; when agitated, pt sits up in bed, tries to get OOB. Managed with 0.5mg ativan which helped pt sleep. Arouses to voice. Knows his own name, recognized his visitors, seemed to understand their inside references. PERRL, good strength in all limbs, able to lift L arm with splint, sometimes holds L arm up, sometimes able to lift L arm, but not able to hold up. Speech is clear. Occ answers that he is in hospital, but has answered, \"Okinawa\" \"deathbed\" \"hell\". Has not correctly stated year nor month of year. Trauma team attempted to clear C-spine, but pt too vague with reporting pain. SO J collar placed back on. Main c/o is having to pee - needs to get up to go to BR and to shower. Asking for coffee. CT scan of head by report shows intraparenchmal bleed as well as sub arachnoid hemmorhage. TLS cleared by x-rays from other hospital.\n Remains on nipride to maintain sys BP less than 140 sys. Going up on nipride this eve. Lopressor 5mg given with little effect on BP. NSR, no ectopy.\n On room air, O2 sats 96-99% even with Nipride on. Respirations unlabored. Breath sounds clear.\n Adequate u/o. Remains NPO.\n Back & buttocks intact. L arm splinted and intact. L fingers warm, sensation intact, able to move L fingers.\n Pt has had friends visit and his ex-wife, pt's daughter and pt's brothers have called for update.\nA: usually somnolent, occ agitated, ativan with effect. Confused as to place & time. Does not remember accident. Nipride dose increased to maintain sys BP < 140.\nP: continue to monitor and treat BP. Re-orient frequently, assess neuro status. ativan as ordered.\n\n" }, { "category": "Nursing/other", "chartdate": "2114-07-10 00:00:00.000", "description": "Report", "row_id": 1265639, "text": "T-SICU NSG NOTE\nNEURO- OPENS EYES TO SPEECH, FOLLOWS COMMANDS, SWALLOWS WITHOUT DIFFICULTY, ORIENTED X2, SLIGHTLY SARCASTIC AT TIMES.\n\nRESP-CL BS 98% ON RM AIR\n\nCVS- NIPRIDE OFF AFTER PO HAYDRALAZINE, AND LOPRESSOR KICKED IN, SBP 120'S WITH GOAL <140. HR 68-71 NSR NO ECTOPY. IVF @ 75CC/HR.\n\nGI- TOL CLEAR LIQUS, ABD SOFT HYPOACTIVE BS.\n\nGU-FOLEY PATENT FOR CLEAR YELLOW URINE IN GD AMTS\n\nSKIN- SCRAPES ON FINGERS, COLLAR INTACT\n\nA: STABLE HOSP COURSE\n\nP:MONITOR VS PER ROUTINE, ORIENT AS NEEDED, TYLENOL FOR HA.\n" }, { "category": "Nursing/other", "chartdate": "2114-07-10 00:00:00.000", "description": "Report", "row_id": 1265640, "text": " \"B\" NPN\n\nCVS: Skin warm and dry. Pulses intact. Left casted arm-fingers warm and movement good. Afebrile. HR=66-75 NSR No ectopy noted. SBP=123-141. IV NS +20meq KCL at 75cc/h\n\nResp: RA sats=96-98%. Lungs clear.\n\nNeuro: Pupils=+, Moves all extremities, follows all commands, answers appropriately for resident. Told nurse to \" his ass\". No c/o H/A.\nc/o pain in left arm-med with MSO4 with good effect. Would not rate pain.\n\nSkin: No reddened areas, no draining wounds.\n\nGI: +bowel sounds, taking clear liquids.\n\nGU: c/o having to \"PEE\" alot. Foley draining adequately u/o=30-105cc/h.\n\nPlan: Increase diet and activity today.\n" }, { "category": "Nursing/other", "chartdate": "2114-07-10 00:00:00.000", "description": "Report", "row_id": 1265641, "text": "npn 7p-3:30 p\n\nsee careview flowsheet\nsee transfer note\n\npt assessed as stable per neuro-; to be transferred to regular floor this afternoon;\n\npt to start anti-coag for DVT prophylaxis;\nfoley may also be dc'd.\n\n" }, { "category": "Nursing/other", "chartdate": "2114-07-09 00:00:00.000", "description": "Report", "row_id": 1265637, "text": "npn\ns=it's .\n\no=transferred from n/sicu to t/sicu after apparent hit and run--pt. was intoxicated according to etoh at outside hosp. of 127. riding bicycle, found on roadside with fragments of vehicle at scene. taken to osh, then transferred to . found to have small sah on ct; left scapular and radial head fxs, both non-displaced. also left arm and finger lacerations with dsd. pupils equal 4mm-reactive to light. moves all extremities--slight difficulty raising left arm with cast and fx. scapula. warm fingers, good cap. refill. able to sit up in bed when attempting to go to br to void. instructed that he has foley cath., but insists that he can go to bathroom. positive pulses bilaterally in lower extremities. no other injuries noted except for abrasions on left upper back.\n\ncv=monitor pattern= nsr rate 90's, no vea. sbp via right radial a-line 120-130's. goal is to keep sbp < 140 on nipride drip. rate much of shift has been 0.95mkm. non-invasive pressures close to or less than a-line pressures. see careview for vital signs. ivf .9ns with 20 kcl at 75cc/hr. kcl and mg repleted.\n\npulm=sats on 2 liters nasal cannula= 96-98%. breath sounds clear bilaterally to bases. pt. is a smoker--unclear how much he smokes. resp. rate=20's.\n\ngi=abdomen soft, non-distended. positive bowel sounds. npo.\n\ngu=foley patent for clear yellow urine. see careview for amts.\n\nskin=as previously noted.\n\nendo=no issues.\n\nheme=hct 34.1. wbc=11.2\n\nsocial=spoke to ex-wife for information. all questions. answered. pt. has two daughters in the area. other family members in ca. both parents expired.\n\na=stable neurologically but very uncooperative at times.\n\np=continue to monitor. repeat ct of head today.\n" } ]

[ { "category": "Radiology", "chartdate": "2153-02-09 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 858767, "text": " 11:11 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST; CT RECONSTRUCTION\n Reason: PLEASE EVALUATE W/ GASTROGAFFIN. r/o abscess, appendicitis\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with diffuse abdominal pain, fever to 101, abdominal\n distention...has poorly-controlled type I diabetes, is 3 weeks postpartum from\n a vaginal delivery.\n REASON FOR THIS EXAMINATION:\n PLEASE EVALUATE W/ GASTROGAFFIN. r/o abscess, appendicitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FKh SAT 4:34 AM\n Free fluid.\n Interloop abscess.\n free fluid x abscess in the pelvis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old woman with diffuse abdominal pain and fever. The\n patient is status post vaginal delivery three weeks ago.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: 8-MDCT axial images of the abdomen and pelvis were obtained with\n oral and IV contrast.\n\n 100 cc of Optiray 350 were administered. Nonionic IV contrast was used due to\n patient debility.\n\n CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: There are small bilateral\n pleural effusions. There are atelectatic changes in the left lung. There is\n no evidence of pneumonia. There is no evidence of pericardial effusion. There\n is an NG tube with the tip in the stomach. There are no focal lesions in the\n liver. The gallbladder is dilated. There is a small focal area within the\n gallbladder that may represent a small stone.\n\n There is a large amount of free fluid in the abdomen. There is enhancement of\n the peritoneum which indicates peritoneal inflammation. There is significant\n stranding into the mesentery. There are fluid collections between the bowel\n loops in the mid abdomen and associated wall thickening. The largest\n collection measures 6.9 x 2.7 cm and has an enhancing wall. The contrast\n passes freely through the small bowel, reaching the colon. There is no\n evidence of bowel obstruction.\n\n The appendix is not identified. There is no evidence of fecalith in the\n abdomen. In the right lower quadrant, there is a soft tissue area that\n appears to be causing some mass effect that measures 4.0 x 2.4 cm.\n\n There is no free air in the abdomen.\n\n (Over)\n\n 11:11 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST; CT RECONSTRUCTION\n Reason: PLEASE EVALUATE W/ GASTROGAFFIN. r/o abscess, appendicitis\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITH ORAL AND IV CONTRAST. The uterus is enlarged but this\n is consistent with recent delivery. There is a large amount of fluid in the\n pelvis. Again, in the pelvis, there is enhancement of the peritoneum which is\n consistent with peritonitis. These fluid in the pelvis communicate with the\n free fluid around the liver. The one in the Douglas Pouch which measures 10 x\n 6.7cm probably communicates with the other fluid. However, follow up after\n drainage could be helpful. The rectum is unremarkable. Perirectal fat is\n unremarkable. The adnexa is unremarkable. There is a small amount of air\n anteriorly in the pelvis that most likely is located within the urinary\n bladder. The appendix is probably seen and within normal limits.\n\n BONE WINDOWS: There are no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n 1) Large amount of free fluid in the pelvis and abdomen with peritoneal\n enhancement and stranding of the mesentery. These findings are consistent\n with ascites and peritoneal inflammation. The sequelae of hemorrhage,\n infection, or both are possible etiologies.\n\n 2) Collections within the mesentary of the small bowel in the mid abdomen. The\n largest one measures 6.9 x 2.7 cm.\n\n 3) Small stone in the gallbladder without evidence of acute cholecystitis.\n\n 4) Small bilateral pleural effusions with associated atelectasis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-14 00:00:00.000", "description": "PERIPHERAL W/O PORT", "row_id": 859314, "text": " 3:04 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: placement of PICC for abx\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 5\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with need for IV abx, failed attempt by IV team\n REASON FOR THIS EXAMINATION:\n placement of PICC for abx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Malpositioned PICC. Bacteriemia.\n\n PROCEDURE: The procedure was performed by Dr. and \n with Dr. , the Attending Radiologist, being present\n and supervising. The right arm was prepped in a sterile fashion. A 0.018\n guidewire was advanced under fluoroscopic guidance into the superior vena cava\n through the existing PICC line in the right antecubital fossa. The PICC line\n was repositioned. The catheter was flushed. A final chest x-ray was obtained.\n The film demonstrates the tip to be in the superior vena cava just above the\n right atrium. The ling is ready for use.\n\n A statlock was applied and the line was heplocked.\n\n IMPRESSION: Successful repositioning of right antecubital PICC line with tip\n in the superior vena cava, ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2153-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 859306, "text": " 2:05 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PICC repositioned; please checkpicc tip placement. thanks \n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with abdominal pain and distention, fever to 101\n\n REASON FOR THIS EXAMINATION:\n PICC repositioned; please checkpicc tip placement. thanks \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 36-year-old woman with abdominal pain and fever. Chest x-ray\n to evaluate PICC line placement.\n\n Portable AP view of the chest dated at 14:23 is compared to the\n same examination at 12:51 on the same day. The right subclavian PICC line is\n still malpositioned with the tip in the left subclavian vein. There has been\n no change since the prior exam 3-1/2 hours earlier.\n\n IMPRESSION: Continued malposition of the right subclavian PICC line catheter.\n from the IV team was notified of this finding.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-13 00:00:00.000", "description": "US RETROPER ABSCESS DRAIN PERC", "row_id": 859124, "text": " 10:31 AM\n US RETROPER ABSCESS DRAIN PERC; GUIDANCE FOR ABSCESS () Clip # \n Reason: drain abscess\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with\n REASON FOR THIS EXAMINATION:\n drain abscess\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Transvaginal ultrasound guided drainage of cul-de-sac abscess.\n\n INDICATION: Patient with postpartum abscess. Uncontrolled diabetes.\n\n TECHNIQUE: The patient's CT scans were carefully reviewed. An initial plan\n to perform a transgluteal drainage of a cul-de-sac sac abscess was abandoned\n in favor of transvaginal technique, as the abscess cavity was difficult to\n access via transgluteal route because of engorged uterine vessels and the\n patient's difficulty with lying prone.\n\n The patient was taken to the ultrasound suite. Conscious sedation with\n fentanyl and midazolam was performed. A preprocedural timeout was performed\n to confirm patient identity and indication for examination. With the patient\n in lithotomy position, the perineum and vaginal vault were cleansed with a\n mixture of Betadine and Xylocaine jelly. Following this, the posterior\n vaginal fornix was anesthetized with lidocaine injection. Using direct\n son visualization, an 8-French catheter was then advanced into\n the heart of the collection. A three-way top setup and nearly 400 mL of\n purulent fluid was aspirated. Postprocedural son examination showed\n good position of the catheter within a largely collapsed collection. Ten mL\n of lidocaine were introduced into the collapsed cavity to ameliorate\n postprocedural pain. The drainage catheter was then secured to the patient's\n right leg. The patient tolerated the procedure well and there were no\n immediate complications. The attending, Dr. , was present and scrubbed\n and assisted throughout the entire procedure. There were no immediate\n complications.\n\n CONCLUSION: Successful ultrasound-guided transvaginal collection drainage.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-12 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 858994, "text": " 1:26 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: look for collections that may be drainable, thanks\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with diffuse abdominal pain, fever to 101, abdominal\n distention...has poorly-controlled type I diabetes, is 3 weeks postpartum from\n a vaginal delivery, had one CT guided drain placed yesterday with 200 cc\n drainage. Now needs another look to see if there is anything more to drain.\n Dr. requesting Dr. . Will call to discuss\n REASON FOR THIS EXAMINATION:\n look for collections that may be drainable, thanks\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with intraabdominal abscess that has been drained\n percutaneously. To assess response.\n\n TECHNIQUE: Axial multidetector CT acquisitions of the abdomen and pelvis were\n acquired on a Volumetric CT imaging unit.\n\n COMPARISON: .\n\n REPORT:\n\n CT OF THE LUNG BASES: Bilateral pleural effusions are identified that have\n increased in size. These are associated with atelectasis. This too has\n increased in size.\n\n CT OF THE ABDOMEN: The liver appears normal. Ascites is present. This is\n unchanged in size. The gallbladder is distended, but otherwise appears\n normal. No definite gallstones are seen. No intrahepatic or extrahepatic\n biliary dilatation. The pancreas appears normal. Spleen is normal.\n\n CT RETROPERITONEUM: Both kidneys appear normal. Both adrenal glands are\n normal. There is good uptake and excretion of contrast bilaterally.\n\n CT OF THE PELVIS WITH CONTRAST: The uterus is enlarged, it is being displaced\n for by large cul-de-sac lesion. Intrauterine fluid consistent with patient's\n recent post-partum state is identified.\n\n As well as a left flank collection, there is some free fluid identified along\n both pericolic gutters. There is extensive intraabdominal loculated\n fluid/abscesses. These are identified within the mesentry and are unchanged\n in size. The patient has a drain along the right flank. This was drained of\n some of the fluid, though extensive fluid is still identified. A possible\n connection between the large cul-de-sac lesion, which is unchanged in size,\n which measures 10 x 8 cm was seen. For this reason, a CT sinogram was done.\n Following injection of contrast, no opacification of the cul-de-sac\n collection is seen. The appearances suggest that this collection requires\n independent drainage.\n (Over)\n\n 1:26 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: look for collections that may be drainable, thanks\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CONCLUSION:\n\n 1) Increase in the pleural effusion, atelectasis, and anasarca. Partially\n drained right flank abscess, with catheter in good position.\n\n 2) Cul-de-sac collection appears discrete requiring further drainage. This\n will be performed at a later stage.\n\n 3) CT of bones shows a benign appearing sclerotic lesion within the left\n femur. No other abnormalities seen.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-15 00:00:00.000", "description": "CT RETROPERITONEAL DRAINAGE", "row_id": 859397, "text": " 10:20 AM\n CT RETROPERITONEAL DRAINAGE; CT GUIDANCE DRAINAGE Clip # \n CT PELVIS W/O CONTRAST\n Reason: multiple abd abscess\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37G3P2 IDDM s/p VAC assist delivery dc'd last week c/b with one week of\n crampy abd pain, distension and 2-3 days of vomiting and decreased flatus. CT\n showed 6 cm abccess and fluid in left mid abdomen. Contrast reached colon.\n Substantial free fluid, no PO contrast extravasation or free air.\n REASON FOR THIS EXAMINATION:\n multiple abd abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-partum with several pelvic abscesses, previously drained now\n with 1 right lower quadrant drain and another transvaginal catheter. The\n anterior lower pelvic collection is not drained by these catheters, for CT\n guided drainage.\n\n PROCEDURE: After the risks and benefits of the procedure were discussed with\n the patient, informed consent was obtained. Preprocedure timeout was obtained\n to confirm the identity of the patient and the procedure, which she has to\n undergo.\n\n CT guided drainage localization. With the patient in a supine position, axial\n CT images were obtained through the pelvis to localize the collection to be\n drained. Two drainage catheters are seen, one in the right lower quadrant and\n the other transvaginal, ending in the space of the prior posterior collection,\n with no significant residual fluid. There is a large anterior lower pelvic\n collection, not significantly changed in size in comparison to the prior CT\n dated . This collection contains a significant amount of air within\n it.\n The patient's skin was prepped and draped in the usual sterile fashion and 1%\n lidocaine was used for local anesthesia.\n\n CT GUIDED CATHETER INSERTION: Under direct CT guidance, and using a Seldinger\n technique, an 8 French self-locking pigtail catheter was inserted and deployed\n into the anterior fluid collection. The catheter position was confirmed using\n CT scanning. The catheter was locked in position, secured to the skin with a\n percutaneous catheter fastener and left open to drain. Approximately 70 cc of\n serosanguineous fluids containing some debris was aspirated from it. Sample\n was sent for Gram stain and culture. There was an attempt first to insert a\n 10 French catheter, but it was difficult to advance it and a decision was made\n to use an 8 French catheter.\n\n Dr. , attending radiologist, was present and supervising the entire\n procedure.\n\n IMPRESSION:\n\n Technically successful drainage of anterior pelvic abscess.\n (Over)\n\n 10:20 AM\n CT RETROPERITONEAL DRAINAGE; CT GUIDANCE DRAINAGE Clip # \n CT PELVIS W/O CONTRAST\n Reason: multiple abd abscess\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-09 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 858762, "text": " 10:09 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o obstruction and free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman s/p NSVD at 34wks on now w/ abd distension, n/v.\n REASON FOR THIS EXAMINATION:\n r/o obstruction and free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: This is a 36-year-old woman with abdominal distention, nausea,\n and vomiting.\n\n TECHNIQUE: AP SUPINE SINGLE VIEW OF THE ABDOMEN: There is an NG tube with\n the tip in the stomach. There is no evidence of small bowel obstruction.\n There is air within the cecum. No abnormal calcifications were seen.\n There is increased density in the abdomen and bowel loops are displaced\n centrally.\n\n IMPRESSION:\n 1. Findings consistent with ascitis.\n 2. No evidence of small bowel obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2153-02-10 00:00:00.000", "description": "PERITONEAL ABSCESS DRAINAGE US", "row_id": 858798, "text": " 10:31 AM\n PERITONEAL ABSCESS DRAINAGE US; GUIDANCE FOR ABSCESS () Clip # \n US ABD LIMIT, SINGLE ORGAN\n Reason: US GUIDED DRAIN PLACEMENT, MULTIPLE PERITONEAL FLUID COLLECTIOSN\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with\n REASON FOR THIS EXAMINATION:\n multiple peritoneal fluid collections\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 2-3 weeks' status post vaginal delivery. Intraabdominal fluid\n collections. Elevated white count.\n\n Dr. was present assisting.\n\n Prior to initiating the procedure, informed consent was obtained. The patient\n identity, procedure site and side were again confirmed with support staff\n present.\n\n The patient was brought to the ultrasound suite and scanned in the supine\n position on the gurney. Initial images demonstrate multiple fluid\n collections, corresponding to those seen on the CT examination performed the\n previous day. Multiplanar images through the uterus again demonstrate a\n postpartum uterus with peripheral flow and a slightly dilated endometrial\n cavity, an expected finding. No echogenic foci or flow are seen within the\n endometrial cavity.\n\n Images through the low pelvic and right abdominal collections demonstrate\n complex, heterogeneous, hypoechoic material. Several thin septations are\n identified. The findings are felt to represent debris, and possibly clot.\n\n Although not the largest collection, the right abdominal collection was\n selected for reasons of safety. The overlying skin was prepped and draped in\n the usual sterile fashion. Local anesthesia was achieved utilizing 1%\n lidocaine. Under direct ultrasound visualization, an 18-gauge needle was\n advanced down into the collection. Location was confirmed with aspiration.\n Aspirate yielded several cc of yellow fluid with debris. Utilizing the\n Seldinger technique, an 8-French catheter was advanced down into the\n collection and secured to the skin. Only minimal fluid was found to drain\n from the catheter. Despite multiple maneuvers with patient positioning, it\n was felt that insufficient material was draining through the catheter.\n\n The procedure site was again prepped and draped in the usual sterile fashion.\n The catheter was removed. At a site approximately 1-1/2 inches medial from\n the original site, an 18-gauge needle was again advanced down into the right\n abdominal collection. Using Seldinger technique, a 10-French catheter was\n advanced down into the collection. Location was again confirmed with\n aspiration. Upon collection of the drainage bag free flow of yellow fluid\n with debris was seen, measuring at least 100 cc. The catheter was secured.\n\n The patient was monitored throughout the procedure by nursing. At the start\n (Over)\n\n 10:31 AM\n PERITONEAL ABSCESS DRAINAGE US; GUIDANCE FOR ABSCESS () Clip # \n US ABD LIMIT, SINGLE ORGAN\n Reason: US GUIDED DRAIN PLACEMENT, MULTIPLE PERITONEAL FLUID COLLECTIOSN\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of the procedure, the patient was tachycardic and maintained a slightly\n elevated heart rate throughout. The patient otherwise tolerated the procedure\n well. The patient was then transferred back up to the floor.\n\n Aspirate was sent as specimen to microbiology.\n\n IMPRESSION:\n\n Placement of 10-French drainage catheter in right abdominal fluid collection\n yielding at least 100 cc of yellow fluid with debris.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 859286, "text": " 12:17 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: please confirm picc ti placement from right arm; page \n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with abdominal pain and distention, fever to 101\n\n REASON FOR THIS EXAMINATION:\n please confirm picc ti placement from right arm; page with results\n thanks. \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old woman with abdominal pain and fever. Please confirm\n PICC line placement.\n\n Portable AP view of the chest dated , at 12:51 is compared with\n prior AP portable chest x-ray of . A right subclavian PICC line\n crosses the midline to enter the left subclavian vein. There is no\n pneumothorax. The NG tube has been removed. The lung fields are clear. The\n heart and mediastinal contours are normal and unchanged. The surrounding\n osseous and soft tissue structures are unremarkable. There is no free\n intraperitoneal air.\n\n IMPRESSION: Right subclavian PICC line crossing midline to enter the left\n subclavian vein. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 858760, "text": " 9:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia, infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with abdominal pain and distention, fever to 101\n REASON FOR THIS EXAMINATION:\n r/o pneumonia, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 36-year-old woman with abdominal pain and fever. Rule out\n pneumonia or infiltrate.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: AP upright single view of the chest.\n\n FINDINGS: An NG tube with the tip in the stomach. The heart is of normal\n size. The mediastinal and hilar contours are within normal limits. The lung\n fields are clear. There are no pleural effusions or focal consolidations.\n\n IMPRESSION: There is no evidence of pneumonia. There is no evidence of free\n air in the abdomen.\n\n" }, { "category": "Nursing/other", "chartdate": "2153-02-10 00:00:00.000", "description": "Report", "row_id": 1414548, "text": "Recieved 36yr old post partum female admitted to 10 on . She arrived from IR s/p placement of peritoneal drain for fluid collection. She was originally admitted febrile with acute abd pain, n/v from hospital. Please see Admission data, MD notes/orders. Neuro: A&O x3. CV: ST/no ectopy, sbp 120's/50's. Pulm: RA sat 96%, lungs clear, very decreased at bases. GU: Uo >50cc/hr clear yellow. GI: Abd softly distended with hypoactive bs. Pt expresses mild tenderness to palpation, No rebound pain. Endo: Insulin gtt initiated at 1 unit/hr. Skin: Temp 99.6 Surfaces intact, peripheral pulses present. Soc: Husband and father in, currently in nursery. Peritoneal drainage bag intact, emptied for 50cc pink fluid with sediment. FEN: NS infusing at 150cc/hr, mag repleted, naphos infusing at 84cc/hr. Lactate 0.8, abg's per careview, most recent glucose 164. pt currently npo. P: Continue to monitor uo/hemodyamics, pulmonary status. Titrate insulin gtt to keep blood sugar 80-120. Lytes/cbc after magnesium comepleted. Encourage respitory hygiene, IS. Pain meds prn for abd pain. Keep family up to date on plan of care. Drain care per IR orders. R: Pt sleeping after morphine 2mg for abd discomfort. Glucose 164 down from 205 with no change in insulin gtt rate. Pt using IS/TCDB with good effort. Family updated with questions answered, all else as above.\n" } ]

[ { "category": "Radiology", "chartdate": "2183-11-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1210125, "text": " 1:02 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: acture process?\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with upper GIB, LOC and head trauma\n REASON FOR THIS EXAMINATION:\n acture process?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SVMc TUE 2:38 PM\n no acute intracranial process - \n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man with upper GI bleeding, loss of consciousness and\n head trauma. Please evaluate for acute intracranial process.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect, or\n other CT evidence of an acute large vascular territory infarct. Mildly\n prominent ventricles and sulci indicate mild cerebral atrophy. There is no\n abnormal extraaxial collection.\n\n There is no fracture. There is mild mucosal thickening of the ethmoid air\n cells. There is a 8 x 4 mm subcutaneous nodule (3:54) in the right frontal\n scalp.\n\n IMPRESSION:\n\n 1. No evidence of an acute intracranial process. No fracture.\n 2. Subcutaneous nodule in the right frontal scalp. Please correlate with\n physical exam.\n\n" }, { "category": "Echo", "chartdate": "2183-11-12 00:00:00.000", "description": "Report", "row_id": 84253, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Murmur. Right ventricular function. Syncope.\nHeight: (in) 71\nWeight (lb): 210\nBSA (m2): 2.16 m2\nBP (mm Hg): 132/71\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 12:18\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Hyperdynamic LVEF\n>75%. Mild resting LVOT gradient. LVOT gradient increases with Valsalva. No\nVSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Focal calcifications in aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). There is a mild resting left ventricular\noutflow tract obstruction. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nIMPRESSION: Hyperdynamic LV systolic function. Consequently there is a mild\nleft ventricular outflow tract gradient during systole that worsens slightly\nwith the Valsalva maneuver. Mild mitral regurgitation.\n\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic function is more vigorous and hence an LVOT gradient has developed.\n\n\n" }, { "category": "ECG", "chartdate": "2183-11-13 00:00:00.000", "description": "Report", "row_id": 226512, "text": "Normal sinus rhythm. Early transition. Borderline P-R interval prolongation.\nLeftward axis. Compared to the previous tracing of , the patient no\nlonger has occasional ventricular premature beats. The tracing is otherwise,\nunchanged.\n\n" }, { "category": "ECG", "chartdate": "2183-11-11 00:00:00.000", "description": "Report", "row_id": 226513, "text": "Normal sinus rhythm. Left anterior fascicular block. Early transition.\nOccasional ventricular premature beats. Compared to the previous tracing\nof no diagnostic interim change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2180-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198137, "text": " 7:48 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: worsening pneumonia?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with trach/peg now agitated, complaining of chest discomfort\n REASON FOR THIS EXAMINATION:\n worsening pneumonia?\n ______________________________________________________________________________\n WET READ: ENYa TUE 11:14 PM\n 1. Interval increase of left retrocardiac opacity, could represent increased\n left pleural effusion and/or worsening of air-space consolidation. No PTX.\n 2. Persistent perihilar hazy opacities, suggestive of mild pulmonary edema.\n 3. Tracheostomy tube at 5.8 cm above the carina.\n 4. Left-sided VP shunt catheter. Right-sided PICC, tip not well visualized.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increasing chest discomfort.\n\n FINDINGS: In comparison with the earlier study of this date, there is\n increasing opacification at the left base in the retrocardiac region. This\n could reflect an increasing effusion, atelectasis, or even some supervening\n consolidation. Apparent shift of the mediastinum to the left suggests\n atelectasis as the major cause.\n\n There is again evidence of mild elevation of pulmonary venous pressure.\n Tracheostomy device, left VP shunt, and right PICC line are again seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1197688, "text": " 11:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with h/o AVM w/ tracheostomy, w/ increased secretions, SOB\n and fever\n REASON FOR THIS EXAMINATION:\n please eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of AVM with tracheostomy, now with increased secretions,\n and shortness of breath and fever, please evaluate for pneumonia.\n\n COMPARISON: No prior studies available for comparison.\n\n FINDINGS: Single portable upright radiograph demonstrates patient with\n tracheostomy in place. Mediastinal, hilar, and cardiac contours are\n unremarkable. Lungs are clear. There is no pleural effusion or pneumothorax\n demonstrated. A partially imaged VP shunt is seen coursing over the left\n hemithorax, into the abdomen.\n\n IMPRESSION: No acute intrathoracic process.\n\n" }, { "category": "Radiology", "chartdate": "2180-06-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1198050, "text": " 9:36 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate for PICC placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with sepsis, PICC placement\n REASON FOR THIS EXAMINATION:\n evaluate for PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of PICC line placement.\n\n COMPARISONS: Prior portable chest x-ray on .\n\n TECHNIQUE: Portable chest x-ray.\n\n FINDINGS: The tip of the PICC line is 5 cm above the cavoatrial junction in\n the mid superior vena cava. Compared with prior chest x-ray, there is an\n increased retrocardiac opacity with air bronchograms that might represent\n atelectasis or pneumonia in the appropriate clinical setting. Lungs are\n normal elsewhere. Cardiomediastinal and hilar contours are normal. A\n tracheostomy tube is observed with the tip 5.5 cm above the carina. Of\n notice, the diameter of its canula is less than half that of the trachea.\n Please consider whether that is the intended size. No pleural effusions or\n pneumothorax are present.\n\n IMPRESSION:\n 1. Tip of the PICC line is in mid superior vena cava.\n 2. Increased retrocardiac opacity consistent with left lower lobe\n atelectasis. However, pneumonia is a probability in the appropriate clinical\n setting.\n 3. Diameter of the cannula of tracheostomy tube is less than half the\n diameter of the trachea. Please consider whether that is intended size.\n\n" }, { "category": "Radiology", "chartdate": "2180-06-03 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1197702, "text": " 1:02 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: LOWER ABDOMINAL PAIN, EVALUATE FOR DIVERTICULITIS, APPENDICITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with h/o AVM/tracheostomy, w/ lower abd pain, L>R\n REASON FOR THIS EXAMINATION:\n please evaluate for diverticulitis, appendicitis, or other acute\n intra-abdominal process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf SAT 4:16 PM\n Small amounts of subq air in the lower abdomen likely related to injections.\n No acute intra-abdominal process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old woman with history of AVM, tracheostomy with lower\n abdominal pain, left greater than right. Please evaluate for diverticulitis,\n appendicitis or other acute intra-abdominal process.\n\n COMPARISON: No relevant comparisons are available.\n\n TECHNIQUE: MDCT images were acquired through the abdomen and pelvis without\n IV or oral contrast due to inability to get IV access. The multiplanar\n reformations were obtained and reviewed.\n\n The partially imaged lungs show mild bibasilar atelectasis. The partially\n imaged heart is unremarkable.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST:\n\n Evaluation of the solid organs is limited due to the lack of IV contrast.\n Within these limitations, the liver has an 11-mm segment VIII lesion (2:8)\n which is hypodense by CT criterion most consistent with a simple cyst. The\n spleen, both adrenals, both kidneys, pancreas and gallbladder are\n unremarkable. The patient has a percutaneous gastrostomy tube with the\n balloon inflated in an appropriate position. Also noted is the partially\n imaged ventriculoperitoneal shunt. No abdominal, retroperitoneal or\n mesenteric lymphadenopathy by CT size criteria is present. No abdominal free\n fluid or free air is present. The small and large bowel loops are\n unremarkable. The appendix is unremarkable. Mild amount of subcutaneous air\n in the anterior abdominal wall inferiorly is likely related to injections.\n\n CT OF THE PELVIS WITH IV CONTRAST:\n\n The rectum, sigmoid colon, uterus and both adnexa are unremarkable. A Foley\n catheter is within the bladder. No pelvic or inguinal lymphadenopathy is\n present. There is a trace amount of fluid in the pelvis, simple.\n\n OSSEOUS STRUCTURES:\n\n The visible osseous structures show no suspicious lytic or blastic lesions or\n fractures. A bone island is noted in the right ilium.\n (Over)\n\n 1:02 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: LOWER ABDOMINAL PAIN, EVALUATE FOR DIVERTICULITIS, APPENDICITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n Mild amount of subcutaneous air in the anterior abdominal wall inferiorly is\n likely related to injections.\n\n Trace pelvic free fluid, could be physiologic (if patient pre-menopausal), or\n could relate to VP shunt.\n\n" }, { "category": "Radiology", "chartdate": "2180-06-06 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1198037, "text": " 8:29 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please do upright, eval for obstruction\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with abd pain, increasing abd distension\n REASON FOR THIS EXAMINATION:\n Please do upright, eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old woman with abdominal pain and increasing abdominal\n distention, question obstruction.\n\n COMPARISON: CT scan from .\n\n FINDINGS: Non-obstructive bowel gas pattern. No free air noted. VP shunt\n can be seen on abdominal x-ray. Gastrostomy tube can also be seen.\n\n IMPRESSION: Normal bowel gas pattern.\n\n\n" }, { "category": "ECG", "chartdate": "2180-06-06 00:00:00.000", "description": "Report", "row_id": 158492, "text": "Sinus rhythm. T wave inversions in leads V1-V3 with non-specific T wave\nflattening in lead V4. These changes are non-specific but cannot exclude\nischemia. Compared to the previous tracing of the precordial T wave\ninversion is new in leads V2-V3.\n\n" }, { "category": "ECG", "chartdate": "2180-06-04 00:00:00.000", "description": "Report", "row_id": 158493, "text": "Probable sinus rhythm. The tracing is marred by artifact. No apparent\nabnormalities. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2194-01-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 991051, "text": " 11:17 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate CVL location (changed over wire)\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with Rt IJ CVL changed over wire (line had been pulled back\n earlier in day and was leaking infused fluid).\n REASON FOR THIS EXAMINATION:\n evaluate CVL location (changed over wire)\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE-VIEW CHEST ON .\n\n Comparison made to prior study the same day. The endotracheal tube has been\n removed. Right IJ central venous catheter has been advanced, now positioned\n in the high right atrium. There is stable hazy opacity projecting over the\n left hemithorax, likely layering effusion. Right lung is clear. Lung volumes\n are low. Heart and mediastinal contours unchanged.\n\n IMPRESSION: Lines and tubes as described. Left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-01-11 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 992135, "text": " 11:02 AM\n PORTABLE ABDOMEN Clip # \n Reason: ?ileus\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with distension\n REASON FOR THIS EXAMINATION:\n ?ileus\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, .\n\n COMPARISON: .\n\n INDICATION: Abdominal distention.\n\n Multiple loops of mildly distended small bowel have developed accompanied by\n air-filled loops of nondistended colon with air identified distally to the\n rectosigmoid region. Observed pattern is most likely due to clinically\n suspected ileus, but followup radiographs may be helpful to exclude the\n possibility of obstruction.\n\n Abdominal drain and pelvic pigtail catheter are noted. In imaged portion of\n the chest, there is apparent left lower lobe atelectasis and effusion\n incompletely evaluated.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 992539, "text": " 7:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval progression of L pleural effusion\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n eval progression of L pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Progression of left pleural effusion.\n\n Portable AP chest radiograph compared to and .\n\n The ET tube tip is 5 cm above the carina. The right internal jugular line tip\n is at the cavoatrial junction. The NG tube tip is in the stomach. There is\n no change in the intra-abdominal tube position.\n\n There is gradual increase in left pleural effusion which is currently large\n and at least partially loculated given the presence of the apical pleural\n fluid component. There is also underlying vascular engorgement which might\n represent volume overload/failure. The heart size is mildly enlarged but\n stable and there is no change in mediastinal contour.\n\n IMPRESSION: Gradual increase in left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-24 00:00:00.000", "description": "MR L-SPINE W & W/O CONTRAST", "row_id": 989317, "text": " 1:01 AM\n MR W & W/O CONTRAST Clip # \n Reason: Eval for lumbar abscess\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 M s/p AAA repair, LS spine surgery, here with intractable back pain, fever,\n hypotension\n REASON FOR THIS EXAMINATION:\n Eval for lumbar abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD TUE 2:44 AM\n S/P L2-L3 fusion by means of interbody device. L2 and L3 bone edema. Inferior\n L2 and Superior L3 enplate erosion/collapse with grossly abnormal signal in\n the disk space. High suspicion for diskitis/osteomyelitis. No epidural\n abscess. Milder abnormal L5-S1 disk/endplate signal but this is likely\n degenerative. Degenerative disk/post. element changes. At L4-5. causes severe\n canal stenosis. MD\n ______________________________________________________________________________\n FINAL REPORT\n MR LUMBAR SPINE\n\n HISTORY: 63-year-old male status post abdominal aortic aneurysm repair with\n spondylodiscitis status post spinal fusion, now with recurrent back pain,\n fever, and hypotension with an outside hospital CT scan showing evidence of\n paraspinal abscess.\n\n TECHNIQUE: Sagittal pre-gado T1, post-gado T1 with fat sat, T2, STIR of the\n lumbar spine extending from the T10/11 through the S3 levels and axial pre-\n and post-gado T1- and T2-weighted images were obtained.\n\n FINDINGS: Comparison is made to preop study from and the postop study\n from .\n\n The conus medullaris is normal in signal intensity and caliber with no\n abnormal enhancement. It normally ends at the T12/L1 level.\n\n There is straightening of the lumbar spine as before.\n\n Again seen are corpectomy changes and erosive changes of the L2 and L3\n vertebral bodies with a bone graft within the disc space. Again seen is\n increased T2 signal and enhancement of the endplates adjacent to the\n intervening disc space and surrounding the bone graft but not significantly\n changed since the prior study. There has been no further loss of height of\n the vertebral bodies. Again seen is a minimal retropulsion as well as\n thickening of the ligamentum flavum and facet arthropathy, the combination of\n which is not causing canal stenosis.\n\n At L3/4, there is a mild disc bulge and facet arthropathy without canal\n stenosis. There is mild right foraminal stenosis.\n\n (Over)\n\n 1:01 AM\n MR W & W/O CONTRAST Clip # \n Reason: Eval for lumbar abscess\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n At L4/5, there is a moderate disc bulge and facet arthropathy as well as\n thickening of the ligamentum flavum, the combination of which is causing\n moderately severe canal stenosis. There is also moderate bilateral foraminal\n stenoses. There is new enhancement and edema of the facet joints with new\n fluid seen within the right facet joint. These findings are concerning for\n new septic arthritis. Multiple small abscesses are seen involving the\n posterior paraspinal muscles at this level, the largest measuring\n approximately 1.5 cm in size. This particular abscess appears to be\n communicating with the adjacent left facet joint. There is also edema and\n enhancement of the posterior paraspinal muscles consistent with myositis.\n\n At L5/S1, again seen is minimal T2 hyperintensity and enhancement of the disc,\n not significantly changed since the prior study without destructive changes of\n the endplates. This likely represents degenerative change but\n spondylodiscitis cannot be completely excluded. There is also a small central\n disc protrusion and moderate facet degenerative changes but without canal\n stenosis. There is some mild narrowing of the subarticular zones as well as\n the foramina bilaterally.\n\n The previously seen large fluid collection within the left psoas muscle has\n essentially resolved. The previously seen abdominal aortic aneurysm is no\n longer visualized consistent with stated history of repair. However, there\n is a loop of small bowel in close apposition to the aorta.\n\n IMPRESSION:\n 1. New enhancement and edema of the facet joints bilaterally at the L4/5\n level consistent with septic arthritis. There are multiple new small\n abscesses within the posterior paraspinal muscles at this level as well as\n myositis of the paraspinal muscles.\n\n 2. No significant change in the postoperative/spondylodisicitis changes at\n the L2/3 level.\n\n 3. Edema and enhancement of the L5/S1 disc as before, which likely represents\n degenerative change, although discitis cannot be completely excluded.\n\n 4. Degenerative changes of the lumbar spine as described above with\n moderately severe canal stenosis at the L4/5 level as before.\n\n COMMENT: The above findings were discussed with nurse practitioner, \n , on at approximately 9:35 a.m.\n (Over)\n\n 1:01 AM\n MR W & W/O CONTRAST Clip # \n Reason: Eval for lumbar abscess\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2194-01-09 00:00:00.000", "description": "CT RETROPERITONEAL DRAINAGE", "row_id": 991841, "text": " 1:15 PM\n CT RETROPERITONEAL DRAINAGE; PUNC ASP ABS HEM BUL CYST Clip # \n CT GUIDANCE DRAINAGE; CT GUIDED NEEDLE PLACTMENT\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: please drain abscess and leave drain in place\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with abdominal abscess (CT )\n REASON FOR THIS EXAMINATION:\n please drain abscess and leave drain in place\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal and pelvic collections requiring drainage.\n\n COMPARISONS: CT of the abdomen and pelvis dated .\n\n PROCEDURE: After explaining potential risks, benefits and alternatives of the\n procedure to the patient, written informed consent was obtained. All\n questions were answered. Patient identity was confirmed using three\n identifiers. A qualified nurse was present to administer 150 mcg of fentanyl\n and 2.5 mg of Versed over 40 minutes, with continuous monitoring.\n\n Unenhanced CT images of the abdomen and pelvis were obtained for localization\n purposes. Images confirmed the presence of perirectal and pericolic fluid\n collections. With the patient in the right lateral decubitus position,\n attention was first directed to the perirectal collection. The left buttock\n skin was marked, prepared and draped in the usual sterile fashion. Using 1%\n lidocaine for local anesthesia and CT guidance, a 10 French catheter\n was placed directly into the collection using a trocar technique.\n Approximately 30 cc of old blood products were aspirated and sent for Gram\n stain and culture. The pigtail was formed and the catheter was secured to the\n skin. Adequate hemostasis was achieved and the patient tolerated the\n procedure without immediate complication. Attention was subsequently directed\n to the left pericolic collection. The skin overlying the left upper quadrant\n was again marked, prepared and draped in the usual sterile fashion and using\n local anesthesia and CT guidance, an 18-gauge spinal needle was inserted\n directly into the collection. Approximately 5 cc of old blood products were\n aspirated from this site and also sent for Gram stain and culture. Adequate\n hemostasis was achieved. Dr. was as essential participant throughout\n the procedure.\n\n IMPRESSION:\n 1. Patient status post placement of a 10-French catheter into the perirectal\n collection and aspiration of a pericolic gutter collection, both of which are\n believed to represent hematomas.\n\n (Over)\n\n 1:15 PM\n CT RETROPERITONEAL DRAINAGE; PUNC ASP ABS HEM BUL CYST Clip # \n CT GUIDANCE DRAINAGE; CT GUIDED NEEDLE PLACTMENT\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: please drain abscess and leave drain in place\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2193-12-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 989980, "text": " 7:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check ET tube, Swan\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man post-op Aorto-BiIliac graft,intubated with Swan, G-tube, J-tube\n REASON FOR THIS EXAMINATION:\n check ET tube, Swan\n ______________________________________________________________________________\n WET READ: DXAe FRI 11:24 PM\n Swan Ganz catheter with tip in the left inferior pulmonary artery . ET tube is\n 2 cm above the carina. No pneumothorax. .\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH\n\n Newly inserted Swan-Ganz catheter whose tip is positioned at the root of the\n left pulmonary artery. The course of the catheter is slightly kinked. Newly\n inserted endotracheal tube whose tip is 2 cm above the carina. No pleural\n effusions, no pneumothorax.\n\n IMPRESSION: Endotracheal tube could be positioned 1-2 cm less centrally.\n Regularly positioned Swan-Ganz catheter, no complications.\n\n" }, { "category": "Radiology", "chartdate": "2194-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990927, "text": " 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate left effusion\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p aortic repair\n REASON FOR THIS EXAMINATION:\n evaluate left effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after aortic repair.\n\n Portable AP chest radiograph compared to and .\n\n The ET tube tip is 3.2 cm above the carina impinging the right tracheal border\n with slight tracheal deviation to the left, should be pulled back for about a\n centimeter to prevent injury to the right tracheal wall. The right internal\n jugular line tip terminates about 5 cm below the cavoatrial junction.\n\n The cardiomediastinal silhouette is stable, but there is increased engorgement\n of the vasculature suggesting worsening pulmonary edema. Large left pleural\n effusion is grossly unchanged and right pleural effusion cannot be excluded.\n\n ADDENDUM: Findings were discussed with nurse practitioner, , at the\n time of dictation by Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2194-01-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990840, "text": " 11:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p exp lap\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male status post exploratory laparotomy.\n\n COMPARISON: .\n\n PORTABLE SUPINE CHEST, ONE VIEW: Tip of right central venous catheter is in\n mid right atrium. Tip of endotracheal tube is 2 cm from the carina.\n Cardiomediastinal silhouette is unchanged. There continues to be diffuse hazy\n opacification of the left hemithorax with preservation of lung markings, most\n consistent with layering pleural effusion. Allowing for differences in\n technique, there is little interval change. Mild atelectatic changes of right\n lung base. No pneumothorax.\n\n IMPRESSION:\n 1. Tip of right central venous catheter in mid right atrium.\n 2. Tip of endotracheal tube is 2 cm from the carina, and may be withdrawn\n approximately 1 cm for better positioning.\n 3. Continued layering left pleural effusion.\n\n Findings discussed by telephone with at the time of\n interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2194-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 990966, "text": " 11:09 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: et tube change/ central line readvance\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n et tube change/ central line readvance\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old male with endotracheal tube change and central line re-\n advancement.\n\n COMPARISON: at 8:50 a.m.\n\n PORTABLE UPRIGHT CHEST, ONE VIEW: Tip of the endotracheal tube is\n approximately 4 cm from the carina, in standard position. The contour of the\n endotracheal tube is again slightly angled, abutting the right tracheal wall.\n Tip of right IJ catheter terminates in the low SVC. No other interval change\n allowing for differences in lung volumes and positioning.\n\n IMPRESSION:\n 1. Endotracheal tube contour is again slightly angled towards the right, with\n the tip abutting the right tracheal wall. The tip is 4 cm from the carina.\n 2. Right IJ catheter tip terminates in low SVC.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-31 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 990526, "text": " 1:59 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: r/o bowel ischemiaUSE CONTRAST VIA IV AND J TUBE\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n r/o bowel ischemiaUSE CONTRAST VIA IV AND J TUBE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male with prior aortoenteric fistula, post-aortic\n surgery, and aorto-bifemoral graft. To assess for bowel ischemia.\n\n TECHNIQUE: CT of the abdomen and pelvis was performed without intravenous\n contrast, followed by CT of the abdomen and pelvis post-administration of\n intravenous contrast. Additional delayed scanning was performed through the\n abdomen and pelvis to assess the portal venous phase.\n\n COMPARISON: With CT of .\n\n FINDINGS:\n\n CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST:\n\n There is extensive coronary artery atherosclerosis present. There is a\n pacemaker present in the right atrium. There are large bibasal effusions with\n passive atelectasis of the lower lobes.\n\n There is a large amount of abdominopelvic ascites. There is a laceration in\n the left lobe of the liver (image 231, series 3B). There are no focal liver\n lesions. The spleen, adrenal glands, pancreas, and kidneys appear\n unremarkable. There is 84 x 50 mm multiloculated collection at the root of\n the mesentery containing pockets of air; this collection abuts the aorta and\n the aortic graft as well as transverse colon and loops of small bowel. This\n collection could represent post-operative seroma versus an abscess.\n\n There is extensive stranding in the mesentry of the abdomen and pelvis with\n thickening of the pararenal fascia all in keeping with recent intra-abdominal\n surgery. There is intense enhancement of the wall of entire small bowel on the\n delayed examination suggestive of sluggish flow. There is no definite\n evidence of bowel ischemia.\n\n There is a gastrostomy tube in satisfactory position and there is also a\n jejunostomy tube in satisfactory position.\n\n CT PELVIS PRE- AND POST-ADMINISTRATION OF INTRAVENOUS CONTRAST:\n\n There is free fluid in the pelvis and inflammatory changes are present in the\n pelvic mesocolon. There is no evidence to suggest bowel ischemia. There is\n no significant pelvic lymphadenopathy.\n\n (Over)\n\n 1:59 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: r/o bowel ischemiaUSE CONTRAST VIA IV AND J TUBE\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n MUSCULOSKELETAL:\n\n There is generalized anasarca. There are post-surgical changes from prior\n osteomyelitis at L2-3 level. There is a bone graft traversing that disc\n space.\n\n CT ANGIOGRAM:\n\n The celiac artery, superior mesenteric artery, and inferior mesenteric artery\n are patent. The superior mesenteric vein and portal vein are patent. There\n is no definite evidence to suggest bowel ischemia. There is a single patent\n right renal artery and a single patent left renal artery. The aortoiliac graft\n is patent.\n\n CONCLUSION:\n\n 1. Large multiloculated cystic lesion at the root of the mesentry containing\n pockets of air is suggestive of post-operative seroma, however, the\n possibility of an abscess cannot be entirely excluded.\n\n 2. Laceration in the left lobe of the liver as described above.\n\n 3. Intense enhancement of the wall of small bowel suggestive of slow/sluggish\n circulation without definite evidence of ischemic/infarcted bowel.\n\n 4. Post-surgical changes in the spine may be further evaluated with an MRI to\n exclude the possibility of (active infection) from old osteomyelitis as\n suggested by the CT of .\n\n 5. Large bibasal effusions with passive atelectasis of the lower lobes.\n\n 6. Large amount of abdominopelvic ascites.\n\n The findings were discussed with in surgical administration by\n Dr. at 4 p.m. on .\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2193-12-29 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 990254, "text": " 9:03 PM\n PORTABLE ABDOMEN Clip # \n Reason: gastrograffin instilled to J tube, r/o leak\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p duodenal repair gtube, jtube, pyloric exclusion, acute\n onset abd. pain this pm\n REASON FOR THIS EXAMINATION:\n gastrograffin instilled to J tube, r/o leak\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain, status post duodenal repair and aortoiliac\n bypass.\n\n ABDOMEN, ONE VIEW: Gastrografin has been instilled through a jejunostomy tube\n in the left lower quadrant without the presence of a radiologist. This\n demonstrates contrast in several small bowel loops. Additionally, there is an\n amorphous area of partially well-marginated contrast in the central portion of\n the abdomen, which is of unclear etiology or significance.\n\n A catheter is seen coming from the right lung apex and terminating over the\n epigastric region, which may represent the previous Swan-Ganz catheter pulled\n back. Additionally, there is a paramidline vertical staple line on the right\n side of the thoracolumbar vertebral column.\n\n IMPRESSION: Contrast in an amorphous partially well demarcated form over the\n mid abdomen; it is unclear as to whether this represents contrast an abnormal\n bowel loop or contrast outside the patient. If clinically indicated, followup\n examination under fluoroscopy or CT is recommended for further evaluation.\n\n Findings discussed with NP cardiothoracic service by\n telephone at time of interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2194-01-08 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 991745, "text": " 9:40 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: IV contrast and contrast via J tube please, check for leak,\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p neo-aorto-iliac surgery, repair duodenum, g tube, j tube\n placement\n REASON FOR THIS EXAMINATION:\n IV contrast and contrast via J tube please, check for leak, started tube feeds,\n tarry stool\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man status post neoaortic iliac surgery and two\n adrenal repair; evaluate for leak.\n\n TECHNIQUE: MDCT images of the abdomen and pelvis were obtained with 130 cc of\n nonionic intravenous Optiray 315 oral contrast. Multiplanar reformations were\n essential to interpretation.\n\n Simple bilateral pleural effusions with adjacent atelectasis are stable.\n Scattered epiphrenic lymph nodes measure up to 9 mm in short axis. Focal low\n attenuation in segment II of the liver appears slightly smaller, measuring 9 x\n 6 mm, compared to 15 x 9 mm on the prior study. This focus is adjacent to the\n anterior abdominal wound. Layering high-attenuation material in the\n gallbladder may represent sludge. The pancreas and adrenal glands are\n unremarkable. A small amount of air is seen in the pancreatic head portion of\n the common duct.\n\n A gastrostomy tube is present. A second percutaneously inserted catheter\n enters in the proximal jejunum and terminates in the duodenal bulb region. A\n left mid abdominal surgical drain terminates near the abdominal aorta at the\n renal artery level.\n\n The patient is status post aortic reconstruction on and moderate\n adjacent fat stranding and non-pathologically enlarged retroperitoneal lymph\n nodes as well as scattered adjacent air locules are seen.\n\n There is no bowel dilatation. There has been interval decrease in the amount\n of free low attenuation fluid throughout the abdomen and pelvis both\n intraperitoneal and retroperitoneal. Scattered discrete rim-enhancing\n collections are more discrete and seen in the following locations: right\n periaortic at the level of the aortic bifurcation measuring 23 x 22 mm, left\n pericolic gutter measuring 8 x 14 mm and deep pelvic measuring 6.6 x 3.9 cm.\n These collections contain no air. There is mild wall thickening of the\n duodenal segment containing the enteric tube, which may be related to the tube\n itself.\n\n PELVIS: The rectum and sigmoid colon are unremarkable. A Foley catheter\n balloon and air are seen in the bladder. The seminal vesicles and prostate\n gland appear unremarkable. Surgical clips are seen in the right groin. There\n (Over)\n\n 9:40 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: IV contrast and contrast via J tube please, check for leak,\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is diffuse stranding of the subcutaneous tissues, compatible with anasarca.\n\n OSSEOUS STRUCTURES: There are no suspicious lytic or blastic lesions. There\n is a healing fracture of the left posterior tenth rib. A bone graft is seen\n in the L2-L3 interspace.\n\n IMPRESSION:\n 1. Multiple rim-enhancing fluid collections are more discrete on the current\n study and abscesses cannot be excluded.\n 2. Stable moderate bilateral pleural effusions, with interval decrease in\n abdominal and pelvic ascites.\n 3. Presumed post-surgical changes adjacent to the abdominal aorta. However,\n infection cannot be excluded.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2193-12-31 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 990478, "text": " 10:10 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval RIJ line\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n eval RIJ line\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right IJ catheter.\n\n FINDINGS: In comparison with the study of , the right IJ catheter has\n been pulled back to the right atrium. The endotracheal tube and nasogastric\n tubes have been removed. The right lung remains clear. On the left, there is\n a vague opacification with preservation of lung markings consistent with\n pleural effusion. Some underlying atelectasis can certainly not be excluded.\n\n Of incidental note is residual contrast material in the colon, possibly from\n the previous CT scan.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-01-17 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 992873, "text": " 12:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval fluid collection, gastrografin via G tube\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n eval fluid collection, gastrografin via G tube\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Status post aorto-enteric fistula repair with increasing\n catheter output.\n\n TECHNIQUE: 0.625 mm helically acquired images are obtained from the lung\n bases to the pubic symphysis with intravenous contrast. Multiplanar\n reformations are provided for interpretation.\n\n FINDINGS: Direct comparison is made to a prior examination dated .\n\n Moderate bilateral pleural effusions again identified with adjacent areas of\n passive atelectasis.\n\n Current examination reveals leakage of Gastrografin administered via the\n patient's gastrostomy tube. This appears to be emanating from the\n duodenojejunal anastomosis and extends inferiorly immediately anterior to the\n aortic vein graft. Additionally, there is a more anteriorly located\n collection of oral contrast within the peritoneal cavity measuring up to 9.5 x\n 1.7 cm to the left of midline. This does appear to communicate with the\n region more posteriorly along the midline. There is no evidence of gross free\n intraperitoneal air. These findings are discussed with the clinical team at\n the time of dictation including Dr. .\n\n The patient's known subdiaphragmatic and juxtaanastomotic drains are noted.\n There is moderate free simple fluid identified about the stomach. There is a\n small loculated appearing perisplenic fluid collection. Additionally, there\n is a small collection at the level of the pelvis to the left of midline\n anteriorly. More dependently within the pelvis, there is a complex-appearing\n fluid which may represent a hematoma related to surgery. Less likely, this\n represents a simple fluid mixing with Gastrografin. Pigtail catheter is\n identified with its distal tip within the pelvis. The previously identified\n fluid collection is nearly completely resolved at this time.\n\n The spleen, pancreas, liver, gallbladder, adrenal glands, and kidneys are\n grossly unchanged and appear grossly unremarkable.\n\n There is diffuse thickening of multiple small bowel loops likely related to\n inflammation within the peritoneal cavity. Additionally, the distal\n descending and sigmoid colon appear mildly thickened.\n\n Remainder of the pelvic structures are grossly unremarkable.\n (Over)\n\n 12:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval fluid collection, gastrografin via G tube\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Again, the patient is noted to be status post aortic repair with vein graft in\n place which appears patent.\n\n No suspicious lytic or blastic bony lesions are identified.\n\n IMPRESSION:\n 1. There is evidence of extravasation of oral contrast into the peritoneal\n cavity as detailed above consistent with anastomotic leak.\n 2. Simple appearing fluid is also identified within the peritoneal cavity,\n predominantly about the region of the stomach.\n 3. Near complete resolution of the previously described pelvic fluid\n collection.\n 4. Moderate bilateral pleural effusions.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2194-01-16 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 992764, "text": " 3:22 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: r/o ptx/assess line placement\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p rt ij line change\n REASON FOR THIS EXAMINATION:\n r/o ptx/assess line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement.\n\n FINDINGS: In comparison with earlier study of this date, the nasogastric tube\n has been pushed further so that the sidehole lies within the upper stomach.\n Endotracheal tube tip is approximately 6.5 cm above the carina. The right IJ\n catheter again lies in the region of the cavoatrial junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 992306, "text": " 6:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M s/p ex lap\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male status post exploratory laparotomy, evaluate CHF.\n\n COMPARISON: .\n\n PORTABLE SUPINE CHEST: Endotracheal tube terminates 3-cm from the carina. Tip\n of a right central venous catheter terminates in the cavoatrial junction. NG\n tube tip is in stomach. Surgical staples overlie the right upper quadrant\n abdomen with an abdominal drain tip overlying the mid abdomen.\n\n Lung volumes are low. Diffuse hazy opacity of the left hemithorax is most\n consistent with a moderate-to-large layering pleural effusion. Since prior\n study, there is minimal change. Additionally, small amount of fissural fluid\n is seen on the right, consistent with a new small right pleural effusion.\n\n IMPRESSION:\n\n 1. Moderate-to-large layering left pleural effusion, unchanged.\n\n 2. Small right pleural effusion.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2194-01-17 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 992898, "text": " 3:01 PM\n CT ABDOMEN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT PELVIS W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: please drain luq abdominal fluid collection that is contrast\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p multiple repairs of duodenal leaks and aoritc aneurysm\n repairs\n REASON FOR THIS EXAMINATION:\n please drain luq abdominal fluid collection that is contrast enhancing\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Status post multiple repairs of duodenal leaks with\n extravasation of oral contrast.\n\n TECHNIQUE: 0.625 mm helically acquired images are obtained from the mid\n abdomen through the pelvis without intravenous contrast.\n\n FINDINGS: Direct comparison is made to prior examination dated at\n 12:54 p.m.\n\n The previously described collection of oral contrast along the anterior\n peritoneal cavity to the left of midline appears nearly completely collapsed\n at this point likely secondary to drainage to the nearby JP drain.\n\n More simple-appearing fluid collections are again identified within the\n peritoneal cavity predominantly about the stomach.\n\n The solid visceral organs are unchanged since the prior exam.\n\n Again, thickening of the loops of small bowel is noted.\n\n Pigtail catheter, and two JP drains is again seen within the peritoneal\n cavity.\n\n Complex-appearing fluid collection seen within the pelvis dependently. This\n may represent hematoma or less likely mixing of oral contrast with free fluid.\n\n IMPRESSION:\n 1. Previously described collection containing extravasated oral contrast\n within the anterior aspect of the peritoneal cavity appears nearly completely\n resolved on the current examination and likely has drained through the JP\n drain. Catheter drainage can therefore not be performed at this time. Findings\n are discussed with Dr. at the time of dictation.\n\n\n (Over)\n\n 3:01 PM\n CT ABDOMEN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT PELVIS W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: please drain luq abdominal fluid collection that is contrast\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2194-01-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 992749, "text": " 1:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with left effusion yesterday\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pleural effusion.\n\n FINDINGS: In comparison with the study of , there is a continued hazy\n opacification of the left hemithorax consistent with the diagnosis of large\n pleural effusion. On the current study, there is increasing opacification at\n the right base, consistent with some combination of effusion, atelectasis, and\n pneumonia. Various tubes remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-01-11 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 992181, "text": " 8:03 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: GB pathology\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with fevers, incr T Bili\n REASON FOR THIS EXAMINATION:\n GB pathology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male with fevers and elevated bilirubin and concern for\n cholecystitis.\n\n COMPARISON: CT abdomen and pelvis, .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is unremarkable without textural\n abnormality or focal lesion. There is no biliary ductal dilatation. The\n common duct measures normal maximal caliber of 5 mm. There is a very small\n amount of ascites layering around the liver. A right pleural effusion is\n incompletely imaged. Shadowing gallstones and probably a small amount of\n sludge is present within the gallbladder neck, but the gallbladder is\n nondistended and there is no wall thickening or adjacent fluid to suggest\n acute cholecystitis. Limited views of the right kidney are unremarkable.\n\n IMPRESSION:\n 1. Cholelithiasis, but no suggestion of acute cholecystitis.\n 2. Small amount of ascites layering around the liver.\n 3. Right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2194-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 991169, "text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusions\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n effusions\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Pleural effusions.\n\n Moderate-sized layering left pleural effusion appears slightly smaller,\n although positional differences may contribute to this apparent change.\n Confluent left retrocardiac opacity and patchy right basilar opacity are not\n substantially changed allowing for differences in lung volumes and technique.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-12-24 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 989421, "text": " 2:17 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: Please evaluate vascular system both for patency and for pos\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with mycotic AAA repair in , on extensive ABX treatment\n months ago, with questiong aortoenteric fistula\n REASON FOR THIS EXAMINATION:\n Please evaluate vascular system both for patency and for possible aorto-enteric\n fistulaALSO: please evaluate Sbuvclavians on both sides\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CTA ABDOMEN AND PELVIS ON .\n\n CLINICAL HISTORY: Mycotic aneurysm, status post Dacron graft repair and\n concurrent L2-3 osteomyelitis, with report from outside hospital stating\n aortoenteric fistula.\n\n TECHNIQUE: Helical acquisition of CT images performed from the thoracic inlet\n through the ischial tuberosities, prior to, during and following intravenous\n administration of 100 cc of intravenous nonionic contrast. No oral contrast\n administered for this exam.\n\n Comparison made to study of .\n\n FINDINGS:\n\n CHEST: Ascending aorta and great vessels are normal in appearance. The heart\n size is normal. There are atelectatic changes throughout the lungs with a\n focal area of ground-glass opacity in the right upper lobe, possibly\n aspiration. Small bibasilar effusions and associated atelectasis. No\n pathologically enlarged mediastinal, hilar or axillary lymph nodes. Coronary\n artery calcifications. A small nonspecific left upper lobe 5 mm nodule is\n noted (series 5, image 19). Continued attention on followup studies should be\n given to this nodule.\n\n ABDOMEN: Liver, spleen, pancreas and adrenal glands are normal. There are\n postoperative changes surrounding the abdominal aorta, with a small locule of\n gas just to the left of the celiac trunk, and suggestion of a small focal area\n of enhancement just inferior to this at the level of surgical clips. There is\n abrupt course change of the infrarenal aorta with anterior angulation and then\n abrupt posterior redirection. In this region, there is persistent perigraft\n fluid, with multiples locules of gas, highly suspicious for graft infection,\n and likely aortoenteric fistula. Just anterior to the most anterior portion\n of the aorta, passes the duodenum, and while there is no direct extravasation\n of contrast into the duodenum, there is no distinct intervening tisse plane.\n Distal to this point, there is thorough opacification of the iliac vessels.\n Celiac trunk, SMA and bilateral renal arteries are widely patent. There is a\n small accessory left renal artery just superior to the main left renal artery.\n Remainder of the abdominal bowel loops are within normal limits.\n (Over)\n\n 2:17 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: Please evaluate vascular system both for patency and for pos\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n PELVIS: Kidneys enhance and excrete contrast symmetrically, without\n hydronephrosis. Pelvic bowel loops are normal in appearance with high density\n stool seen distally, likely from prior oral contrast administration. Trace\n free fluid in the deep pelvis. Bladder is normally distended. Seminal\n vesicles and prostate are unremarkable.\n\n There are post-surgical changes from prior osteomyelitis at the L2-3 level.\n There is bone graft material traversing that disc space. Additionally, there\n is mild haziness to the paraspinous musculature, and a small 1.4 cm\n peripherally enhancing locule adjacent to the L5 spinous process, suspicious\n for a small abscess.\n\n IMPRESSION:\n 1. Gas and fluid within and surrounding the abdominal aortic Dacron graft,\n just superior to the renal veins, at the level of the duodenum, all compatible\n with aortoenteric fistula and infected graft. No direct extravasation of\n contrast material. Patent, opacified distal aorta and iliac vessels, as well\n as all major branch vessels.\n 2. Postsurgical changes from prior(or ongoing) osteomyelitis at the L2-3\n level with indwelling graft material. Focal enhancing collection adjacent to\n the L5 spinous process, 1.5 cm collection adjacent to the L5 spinous process\n as described. Consider MRI for further evaluation.\n 3. Tiny bibasilar effusions and atelectasis with focal area of pneumonitis,\n possible aspiration in the right upper lobe.\n Discussed with Dr , 5pm, .\n\n\n" }, { "category": "Radiology", "chartdate": "2193-12-24 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 989424, "text": " 2:18 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: Request CT of Lumbo-sacral spine to evaluate for pseudoarthr\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p L2/L3 vertebrectomy / fusion and mycotic AAA repair in\n , now with new fever and positive blood cultures.\n REASON FOR THIS EXAMINATION:\n Request CT of Lumbo-sacral spine to evaluate for pseudoarthrosis. Please call\n with questions.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT LUMBAR SPINE\n\n HISTORY: 63-year-old man with L2/3 vertebrectomy and fusion with mycotic\n aneurysm repair, now with new onset of fevers and positive blood cultures.\n Assess for pseudoarthrosis.\n\n TECHNIQUE: CT of the lumbar spine was performed extending from the T11/12\n through the S1 levels with 3.75-mm axial and 2-mm coronal and sagittal\n reconstructions after 100 cc of Optiray IV contrast was given for a concurrent\n CT of the torso.\n\n FINDINGS: Comparison is made to MRs the lumbar spine from and\n .\n\n Partially imaged is a loop of small bowel sitting adjacent to and surrounding\n the abdominal aorta suggestive of aortic-enteric fistula. This is much better\n evaluated on the concurrent CT of the torso.\n\n Again seen are corpectomy and erosive changes of the L2 and L3 vertebral\n bodies with a bone graft material present as before. There is wide lucency\n surrounding the bone graft with erosion of portion of the inferior endplate of\n L3. No bony fusion across the disc space is seen.\n\n Several small erosions are seen involving the left L4/5 facet joint. Several\n small posterior paraspinal abscesses are seen at the L4 and L5 levels, which\n are better evaluated on the MRI.\n\n Again seen are degenerative changes of the lower lumbar spine as previously\n described.\n\n Previously seen left psoas fluid collection has essentially resolved with some\n minimal residual remaining.\n\n IMPRESSION:\n 1. Lucency surrounding the bone graft at the L2/3 level with no bony fusion\n across the disc space. These findings may represent pseudoarthrosis.\n\n 2. Small subarticular erosions of the left L4/5 facet joint, suggestive of\n septic joint, given the MRI findings.\n (Over)\n\n 2:18 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: Request CT of Lumbo-sacral spine to evaluate for pseudoarthr\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Partially visualized is what appears to be an aortoenteric fistula. Please\n refer to the concurrent CT of the torso for full description of this finding.\n\n 4. Multiple small posterior paraspinal muscle abscesses.\n\n COMMENT: The above findings were discussed with Dr. on at\n approximately 4:15 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-24 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 989428, "text": " 2:47 PM\n DUP EXTEXT BIL (MAP/DVT); ART EXT SGL LEVEL Clip # \n Reason: Vein mapping ofr boths LE's please valuate both SUPERFICIAL\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n Vein mapping ofr boths LE's please valuate both SUPERFICIAL and DEEP systems\n with attention to Profunda's on both sides.\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VENOUS MAPPING \n\n INDICATION: Venous roadmapping of the right and left deep and superficial\n femoral veins requested.\n\n FINDINGS:\n\n The right common femoral vein measures 1.36 cm in diameter. The right deep\n femoral and superficial femoral veins both measure 0.73 cm in diameter at\n multiple levels in the right thigh.\n\n The left common femoral vein measures 0.95 cm. The left deep femoral vein\n measures 1.14 and 0.94 cm in diameter in the upper thigh. The superior aspect\n of the left superficial femoral vein measures 0.59 cm. The mid-to-lower\n aspect of the left superficial vein, femoral vein is duplicated. The medial\n moiety measures 0.38 cm in diameter, while the lateral moiety measures 0.52 in\n the mid thigh and 0.94 cm just above the left knee.\n\n The right brachial artery systolic pressure measured 138 mm/Hg, the left 142.\n\n\n" }, { "category": "Radiology", "chartdate": "2194-01-02 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 990783, "text": " 5:45 AM\n PORTABLE ABDOMEN Clip # \n Reason: STAT please - eval for interval change\n Admitting Diagnosis: AORTIC ENTERIC FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n STAT please - eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pain.\n\n There is a paucity of bowel gas within the abdomen. There is a J-tube, the\n tip of which is not well visualized. There are multiple surgical staples\n overlying the abdomen. There is degenerative change in the lumbar spine. The\n tip of the Swan-Ganz catheter is no longer seen.\n\n IMPRESSION: Paucity of bowel gas in the abdomen. J-tube again seen.\n Surgical staples. Degenerative change in the lumbar spine.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-28 00:00:00.000", "description": "Report", "row_id": 1311840, "text": "Respiratory Care:\nPatient remains on SIMV/PSV ventilatory support with no parameter changes made throughout the night. ABG results determined a mild, partially compensated metabolic alkalemia with very good oxygenation on the current settings.\n\nRSBI = 27 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-28 00:00:00.000", "description": "Report", "row_id": 1311841, "text": "SAT 7A-7P\nROS:\n\nNEURO: SEDATED ON PROPOFOL GTT. AROUSES TO VOICE. PUPILS UNEQUAL {L>R} BRISK & REACTIVE. MAE; FOLLOWS COMMANDS. PAIN CONTROLLED WITH FENTANYL GTT; ASSESSED BY VITAL TRENDS AND GRIMACING. AFEBRILE. WIFE CALLED THIS AM & UPDATED ON PT'S CONDITION/POC.\n\nCV: NSR 60-70S. >150S SELF LIMITING AND ASYMPTOMATIC. NO ECTOPY NOTED. CCO PA CATHETER IN PLACE. SVO2 >70 CI >2. SEE CAREVUE FOR FILLING PRESSURES. SBP 90-130S {GOAL 100-120}. TRENDING CARDIAC ENZYMES X2 MORE. PALPABLE PULSES TO LLE; DOPPLERABLE TO RLE. HCT REMAINS STABLE. SQ HEPARIN DECREASED TO FOR DVT PROPHLYAXIS. COMPRESSION SLEEVE TO LLE.\n\nRESP: REMAINS ORALLY INTUBATED ON CPAP+PS 40% 5PEEP 5PS. ADEQUATE ABGS. LS CL. SUCTIONED FOR (-) SECRETIONS. 02SAT >98%.\n\nGU/GI: FOLEY TO GRAVITY WITH HUO >40CC. ABD SOFT (-)BS. G/J TUBES TO GRAVITY BOTH WITH BILIOUS DRAINAGE. NO MEDS; NPO. LACTATE RETURNS TO NORMAL. LIQ BROWN STOOL X2. GUAIC (+).\n\nENDO: GLUCOSE COVERAGE PER RISS PROTOCOL.\n\nSKIN: RASH COVERING UPPER TORSO; IV BENADRYL PRN. ABD INCISION DRAINING LARGE AMOUNTS S/S DRAINAGE SATURATING DRESSINGS. VASCULAR TEAM AND MD AWARE.\n\nPLAN: CONTINUE TO MONITOR HEMODYNAMICS, CARDIAC ENZYMES & HCTS. ?EXTUBATE IN AM?\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-28 00:00:00.000", "description": "Report", "row_id": 1311842, "text": "7pm-11pm\n\nNeuro Awake on propofol and fentanyl. Follows commands.\nNodded yes to pain. Fentanyl increased by 25mcg.\n\nCv/resp VSS bp stable. afebrile. vented on cpap 5/5. no vent changes. Suctioned for sm. amt of white thick sputum. o2 sats wnl.\n\ngi/gu NPO mod amt loose stool x1 Guiac +. foley with amber q.s. uop. Jtube/Gtube to gravity.\n\ninteg abd. dsg in need to be changed for sanginous saturation. Reinforced at distal end.\n\nReport given to Noc nurse. Continue plan of care. Monitor for bleeding. Keep sedated for tonight.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-29 00:00:00.000", "description": "Report", "row_id": 1311843, "text": "CVICU NPN 2300-0700\nNEURO: ON FENTANYL 100MCG/HR AND PROPOFOL 25MCG/KG/MIN GTTS FOR SEDATION, BUT AROUSABLE TO VOICE AND FOLLOWS COMMANDS. MAE. PUPILS UNEQUAL AS DOCUMENTED, LEFT LARGER THAN RIGHT.\n\nCV: SB/SR, NO ECTOPY. HYPOTENSIVE AT BEGINNING OF SHIFT - FENT/PROP DOSES DECREASED, B/P INCREASED SLOWLY. CI > 2 VIA CCO SWAN, RECALIBRATED PER PROTOCOL. HCT STABLE X2 THIS SHIFT AT 30. ABD INCISION DRAINING COPIOUS AMOUNTS OF SEROSANG DRAINAGE - DR. AWARE. OTHER DRESSINGS AS DOCUMENTED.\n\nRESP: ORALLY INTUBATED, ON CPAP 5/5/30%. ABG WNL. L/S CLEAR. SXN FOR SMALL AMTS OF WHITE/CLEAR SECRETIONS.\n\nGI: NPO. G & J TUBES TO GRAVITY. NO BS. SM AMT OF LIQUID STOOL NOTICED WITH BATH.\n\nGU: FOLEY PATENT, AMBER URINE. HUO AS DOCUMENTED.\n\nID: AFEBRILE. WBC 19.3 THIS AM. ON TRIPLE ABX COVERAGE.\n\nSOCIAL: NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN: ? D/C PROPOFOL & EXTUBATE. PAIN MANAGEMENT. FREQUENT WOUND CARE. FREQUENT SKIN CARE.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-29 00:00:00.000", "description": "Report", "row_id": 1311844, "text": "Respiratory Care:\nPatient remains on CPAP/PSV with no parameter changes made throughout the night. Latest abg results determined a mild mixed alkalemia with very good oxygenation on the current settings.\n\nRSBI = 12 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-14 00:00:00.000", "description": "Report", "row_id": 1311874, "text": "neuro-paralytic dcd on prior shift. continues on versed & fentanyl sedation. non-responsinve to any stimuli. perla @ 4mm/ becoming htn with turning and dsg changes this am.\n\ncv- nsr no ectopy. K+ repelted x1. levo weaned to off.transfused 1uprbc for hct=26.6\n\nresp- continued on cmv . not overbreathing ht event. abg wnl. ls course-> clear.\n\ngi- abd firm & distended. absent bs. retention sutures closed. nidline incision seeping copious amounts serousang fluid. JP x2 with BRB. gastric tube drg brownish/red/bilious fluid.duodenaljejunostomy drg light red fluid.ogt-lcwsx witih scant bilious secretions. rt leg incison drg large amts serous fluid. pt on TPN.\n\ngu- adeq. hourly u/o.\n\nlabs- k+/ glucose levels covered with ssc.\n\nplan- repeat plts and transfuse 1uffp. dc ivf. wean versed & fentanyl as tolerated. ??start lasix and beta blocker.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2194-01-14 00:00:00.000", "description": "Report", "row_id": 1311875, "text": "Respiratory Care\nPatient received on AC 500x14 50% +5, breath sounds bilaterally clear, dimininished at the right base, suctioned for small amounts of thick pale yellow secretions, paralytic has been stopped, sedations weaned off,patient still not following commands, extremities look edematous, has been switched to PSV, follow-up ABGs was excellent, plan is to extubate tommorrow when patient neurology hopefully improves.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-03 00:00:00.000", "description": "Report", "row_id": 1311859, "text": "Resp Care\n\nPt is S/P repair of leaking AAA graft which was infected. Pt vented overnight on SIMV mode. RSBI this morning was ~ 80. Plan is for moderate paced wean and extubation later today. Pt sx for scant secr only. ABG , good oxygenation on 50% and +5, and metabolic acidosis compensated by ventilation.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-03 00:00:00.000", "description": "Report", "row_id": 1311860, "text": "NEURO- SEDATED ON PROPOFOL @ 90MCGKGMIN. FACIAL WINCING WITH W->D DSG CHANGED. MEDICATED WITH 0.5 MG DILAUDID. PERLA. NO NON-PURPOSEFUL MOVEMENTS.\n\nCV- NSR NO ECTOPY. NTG GTT TO KEEP SBP 100-120.ATC LOPRESSOR. AFEBRILE. CONTINUES ON TRIPLE ABX. +PP. 3+ GENERALIZED EDEMA.\n\nRESP- VENTED ON SIMV 50& RR=12. RSBI=80%. LSC. METABOLIC ACIDOSIS TX WITH 2 FLUID BOLUSES AND DECREASE IN RR.\n\nGI- ABD WITH MIDLINE DUODENUMOSTOMY INCISION PARTIALLY OPEN BETWEEN STAY SUTURES. W->D DSG CHANGED. INCISION PINK/CLEAN. G-TUBE,D-TUBE DRG BILIOUS DRG.J-TUBE CLAMPED. ON TPN.\n\nGU- ADEQ. HOURLY U/O.\n\nLABS-K+ REPLETED X3. CA+ REPLETED X1. GLUCOSE =155,COVERED WITH 6U REG INS.\n\nPLAN- WEAN,WAKE AND EXTUBATE. MONITOR ABD.DRG. KEEP SBP 100-120.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2194-01-02 00:00:00.000", "description": "Report", "row_id": 1311855, "text": "npn: 1900-0700\nevents: at 0515 pt awoke with a sudden onset of sharp pain in left lower quad. pain. pt bp increased to the 170's and pt was crying in pain stating the he could feel the pain radiating to left shoulder. ekg was done vascular and csru residents were called. labs were sent, abg was taken. pt started to have multiple loose stools that were guaic positive. stools are brown in color. g tube dose not appear to be draining at this time surgery aware. pt recieved a dose of 4mg ivp zofran for n/dry heaves and 25mcg of fent on top of dilaudid pca. pt had kub done and surgery came by to consult. work up pending at this time.\n\nneuro: pt is alert and oreinted times three. pt is at times confused dilaudid pca but will reorient quickly. mae times three. follows commands.\n\ncv: afebrile--nsr 55-80's. sbp 110-170's. iv lopressor dose was help at 0400 2/2 hr in the 50's. ppp bilaterally. skin warm dry with rash present.\n\nresp: lungs clear diminished at bases, pt was on 2lnc but when he awoke with this acute pain he was placed on face tent for increased wob 25-35 and a sat 88-93%.\n\ngi/gu: gtube/j tube in place. g tube draining brown to green drainage. md's were made aware that g tube drainage looked more brown then bilious. foley cath in place meeting goal of uop of 30/hr.\n\nskin: rash. right upper thigh graft site that is oozing s/s. abd stapled.\n\nplan: monitor pain, icu care at this time.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-02 00:00:00.000", "description": "Report", "row_id": 1311856, "text": "respiratory care\npt on the vent changes made tol fairly well. see respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-03 00:00:00.000", "description": "Report", "row_id": 1311861, "text": "7a-3p\nNeuro: Received pt sedated on propofol. Weaned sedation to off. mae's, follows commands, can lift head off pillow. Iv push dilaudid given for pain with vital signs changes, then nonverbal cues to incisional area. 0.5-1mg iv push dilaudid with good relief.\n\nCV: sr-st no ectopy, lopressor q4h for sbp>120, nitro drip increased for sbp 140's-150's. Hydralazine given 10mg iv push with sbp 120's after. Team aware of htn, no new orders. Palpable pulses, 4+ edema anasarca, ozzy incisions see flowsheet. k repleted. central line pulled back by np cxr confirmed line ok to use.\n\nResp: pt received in simv 50% 8/5. weaned to cpap 5/5 resp. abg continues to show respiratory alkalosis. Pt continues to pull tidal volumes between 600-1000cc at a rate of 17. Ls coarse and dim, sx for thick white secretions, et adjusted by resp 1cm out np out. post cxr confirmed tube in good position. sats 96% on cpap 5/5.\n\nGI/GU: abd no bs, soft, tpn for nutrition. Foley draining adequate amounts of urine, see flowsheet for g tube/ duodenostomy drains. j tube clamped at all times, no meds or tube feeds through any tubes per vascular team.\n\nSkin: see flow sheet for incisions/ skin\n\nEndo: riss per cvicu scale.\n\nPlan: Extubate when ok'd by team, bp control sbp<120's, monitor bilious drainage, bs control, wound care, ? when extubated kinair bed, pain mgmt.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-03 00:00:00.000", "description": "Report", "row_id": 1311862, "text": "nursing add 1500-1900\nPt extubated to 50% FT without incident. A&Ox2. Reoriented to date. ivp lopressor increased and hydralazine started as standing order, able to wean nitro. NP accepting higher bp, sbp <140. Plan for PICC line insertion and CVL removal possibly tomorrow. Copious serous drainage from all iv insertion sites/suture lines- freq dsg changes.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-02 00:00:00.000", "description": "Report", "row_id": 1311857, "text": "Went to OR for exploratory lap in AM, came back intubated & vented\n\nNeuro: pt was A&O x3 before went to the OR, screaming & moaning in pain, said \"just give me a gun\", came back from OR sedated, propofol shut off, MAE's, following commands, PERRL 3mm brisk; nodding head appropriately\n\nCV: Afebrile; SR-ST 80's-110's, team awared, SBP 120's-150's, started on NTG gtt, ATC lopressor with minimal effect, IV hydralazine PRN; extremities warm & dry to touch, palp pulses x4; CVP 6-10; 2L LR bolus given & 5% albumin given x1 post op\n\nResp: Lung sound clear, was on face tent with NC d/t inc WOB in AM, came bcak from OR intubated & vented, currently on CPAP 50% FiO2, 5 PEEP, 10 PS; ABG showing metabolic acidosis, correct with fulid bolus & 1 amp bicarb given; L pleural effusion; awaiting vascular team on decision on placing CT\n\nGI: Abd soft, very hypo bowel sound, duodenostomy made in OR and draining tube placed, ABSOLUTELY NO FLUSING OR ANYTHING THROUGH G TUBE OR DUODENAL TUBE, J tube clamped, can be flushed q^h to maintain patency; currently on TPN\n\nGU: Foley draining amber/yellow urine, UO adequate, improved with fluid bolus\n\nInteg: Breakdown @ coccyx area, allevyn dressing applied, see carevue for details\n\nPain: c/o pain all over, PRN fentanyl IV\n\nEndo: Cover per protocol\n\nID: cont on multiple ABX\n\nSocial: Family called & updated\n\nPlan: wean & extubate, correct metabolic acidosis; pain management; wound care\n" }, { "category": "Nursing/other", "chartdate": "2194-01-02 00:00:00.000", "description": "Report", "row_id": 1311858, "text": "pt put back on SIMV 50% 5/10, keep sedated & vented overnight; ABG now showing respiratory alkalosis, increased propofol, will recheck in 2 hrs\n" }, { "category": "Nursing/other", "chartdate": "2194-01-12 00:00:00.000", "description": "Report", "row_id": 1311868, "text": "Neuro-alert/oriented x3 pleasant and cooperative with care. voiceing needs and concerns. vasc/gi/gen.surgery in to see/assess pt in regards to GIB..EGD procudure explained to pt,all questions answered and consent approved by pt.\n\nEGD performed at bedside by GI MD.(see their notes). pt given ivcs with total of 0.5mg versed and 75mcg fentanyl. pt continuously monitored by RN during procedure.procudure performed without incidence.\n\nPrior to procedure pt received 1uprbc & 2 units ffp. labs pending.\n\nPost procudure: pt vss. 1hr later pt found to be extremely hypotensive/tachypneic de-satting and unresponsive,requiring agressive stimuli to respond. quickly returns to \"stupor\" when not stimulated.IVF wide open,0.4mg Narcan x2 with initial response then falls back into lethargy/unresponsiveness. 2uprbc given.\n\nPt continues to be agressively treated by nursing and vasc.md.\n\n\n\n\n\n\n\n\n \u0013\n" }, { "category": "Nursing/other", "chartdate": "2194-01-13 00:00:00.000", "description": "Report", "row_id": 1311869, "text": "Respiratory Care:\nPt returned from OR intubated and vented. S/P repair of neoaortic graft. Currently on AC 500x14 50% 5p. Will keep paralyzed and sedated. No RSBI done.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-13 00:00:00.000", "description": "Report", "row_id": 1311870, "text": "pt returned form the OR around 2300 intubated on Levo. pt had an exploratory lap , SBR x3, duoenojejunostomy, G tube, J tube and Repair of aortic vein graft with fascial pledgits. Pt was found to have an aleoaortic rupture and Duodenal dehiscence. Pt receved a large volume of blood products while in the or. pt was transfered to CSRU on Levo, Propofol started on arrival at 30mcg and then pt paralzed with Cisatrucurium and Sedated with fentanyl for pain. pt required 3 FFp for elevated coags. and a total of 3 units of PRBC (2 have been given the 3rd is to be hung)\nNeuro: pt s baseline was 4 facial twitches on an MA of 20 pt started on cisatracurium at 0.06mg and Fentanyl 100mcg. pt has been twitches. Pupils equal and reactive.\nResp: Fully vented see flow sheet for settings. Breath sounds clear.\nC/V: pt on Levo 0.25mcg on arrival to unit. BP intially dipping requiring 500cc LR pt also given 500cc Albumin 5%, 1 unit PRBC's and 3 UNit of FFP with this Levo was able to wean down to 0.08mcg. Hct this am dropped to 23 so pt receving an additional 2 untis of PRBC. Heart rate in the 90's to low 100's no ectopy. CVP 10-11, bladder pressure 8 on arrival up to 14 this am.\nGI: NGT draining bilious to dark reddish brown. G tube draining bilious but has changed more to red fluid and J tube draining scant amounts of pink tinged fluid.\nEndo: Blood sugars within normal limits.\nGU: output dropped off to 0 after arriving from OR improved overnight with volume.\nSkin: abdominal incision clean draining small amount of serous sangunious drainage. JP to bulb suction drainag moderate amounts of blood fluid. pt also has a pigtail drain in his left lower back draining scant amounts of serous fluid. No breakdown noted on backside pt on air bed. Right leg incision intact with staples no redness draiange or swelling noted.\nPain: pt on Fentanyl drip no changes in Vitals noted. to start on versed and have propofol d/c'd.\nID: pt on several antibiotics all resumed and given through night , see for meds and doses.\nPlan: monitor bladder pressures every shift, Repeat HCt after 2 units given. Remains sedated and paralzed.\nFamily updated over phone\n" }, { "category": "Nursing/other", "chartdate": "2194-01-13 00:00:00.000", "description": "Report", "row_id": 1311871, "text": "Respiratory Care\nAfebrile, into Sinus Tachycardia whole shift, remains paralyzed, no vent changes made, breath sounds essentially clear, suctioned for very minimal amount of secretions, will continue to receive mechanical ventilatory support.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-13 00:00:00.000", "description": "Report", "row_id": 1311872, "text": "PROB: SEPSIS\n\nCV: LEVO TITRATED TO KEEP MAP>60 AND SBP>90. SR-ST RARE PVC NOTED, LYTES WNL. HYPOTENSIVE WITH LOW CVP, AROUND NOONTIME GIVEN 500ML LR WITH GOOD RESPONSE. R RADIAL ALINE INSERTED, L FEM ALINE TO BE D/CD BY RESIDENT. PLT CT 58, HIT SENT. HCT 32 AFTR 2ND UNIT PRBCS GIVEN. R LEG DRAINING S/S DRAINAGE, DSD APPLIED.\n\nRESP: LUNGS COARSE, DIM IN BASES. SUCTION FOR SCANT TAN. ABGS AND O2 SATS ADEQUATE.\n\nGU: UOP ACCEPTABLE.\n\nGI: G TUBE DRAINING BILIOUS-COPIOUS, J TUBE WITH SCANT SEROUS DRAINAGE. NGT DRAINING BILIOUS. NO BOWEL SOUNDS NOTED. ABD FIRMER ON LEFT SIDE, SOFTER ON R SIDE, NO BOWEL SOUNDS PRESENT.\n\nNEURO: CISATRACURIUM CONT, TITRATED TO . PROPOFOL SWITCHED TO VERSED, FENTANYL INCREASED FOR SPIKE IN BP WHEN TURNING.\n\nID: WBC ELEVATED AND CLIMBING. MRSA/VRE IN BLOOD/WOUND.\n\nENDO: BS 60'S, LFT'S BUMPED.\n\nSKIN: COCCYX REDDENED, NO BROKEN AREAS, ALOE VESTA BARRIER CREAM APPLIED. PT ON AIR MATTRESS.\n\nSOCIAL: DAUGHTER CALLED IN, UPDATED.\n\nASSESSMENT: LESS LABILE.\n\nPLAN: PULM HYGIENE.\nMONITOR LYTES/HCT/BS/COAGS.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-01 00:00:00.000", "description": "Report", "row_id": 1311853, "text": "NEURO: Pt alert, oriented x3, follows commands, helps with turns in bed, c/o incisional pain, on PCA Dilaudid with good pain relief (), CT scan done for increased abd pain, no acute changes noted\n\nRESP: Sats 98% on RA, lung sounds dim on bases, Pt encouraged to cough/deep breath\n\nCV: SB-NSR, had two episodes of Sinus Tachy in 130-140s, notified PA, lytes being checked, SBP 110-140s (goal <120 on IV Lopressor/IV Hydral), pedal pulses palpable\n\nGI/GU: Pt to remain NPO, G tube to gravity draining bilious, J tube clamped, TPN started last night, abd has midline incision (appears clean/dry/intact), +BS, FIB intact draining liquid stools; Foley to gravity draining amber/clear urine at >30ml/hr, lytes being checked\n\nENDO: On SSRI\n\nID: Continues on IV Aztreonam (Staph), Daptomycin (VRE), Fluconazole (yeast), afebrile overnight, WBC trending down to 16\n\nSOCIAL: No phone call or visit from family overnight\n\nPLAN: Continue to check for pulses on legs, IV abx for infection, SBP < 120, pain management, ?transfer to VICU/ 5\n" }, { "category": "Nursing/other", "chartdate": "2194-01-01 00:00:00.000", "description": "Report", "row_id": 1311854, "text": "Neuro: A&O x3, MAE's, slow to response sometimes, calm & cooperative otherwise; MAE's, following commands consistently; PERRL 3mm brisk\n\nCV: Afebrile; SR 70's-90's, SBP 110's-140's, IV lopressor q4h, tolerating well, IV hydralazine PRN for SBP >120, given x2; palp puylses x4, skin warm & dry to touch\n\nResp: Lung sound clear, dim @ bases, initially on RA, sat 96-98%, later in shift desat to hogh 80's-low 90's, 2L NC applied, sat 99% now; non-productive cough\n\nGI: NPO, G-tube to gravity with bilious drainage, J tube clamped, nothing through G/J tube; FIB intact; on TPN\n\nGU: Foley draining amber clear urine; UO marginal, team awared, OK with UO >30ml/hr\n\nInteg: Rash on upper body, tapering solu-cortef dose to 25mg q8H; see carevue for details\n\nEndo: Cover per protocol\n\nID: On multiple ABX for yeast, VRE & MRSA\n\nSocial: Brother in for visit\n\nPain: On PCA, dilaudid 0.12/6/1.2 initially, pt still c/o pain when moving, basal rate added @ 2mg/hr with previous setting\n\nActivity: OOB to chair with 3 assist, dangled for short distance, hoyered back to bed\n\nPlan: pain management; pulm toilet; transfer to VICU when bed available; cont on ABX, ?need for PICC line for long term ABX treatment; cont on TPN\n" }, { "category": "Nursing/other", "chartdate": "2194-01-04 00:00:00.000", "description": "Report", "row_id": 1311865, "text": "\n NEURO A/O RELAXED GOOD PAIN CONTROL PLEASE SEE CAREVIEW FOR DETAILS MAE LIMITED BY GROSS EDEMA SLEEPING AT PRESENT\n HEART S1S2 NSR BORDERLINE HIGH BP MD AWARE MULTIPLE MEDS USED FAIR EFFECT VSS MILD NVD NOTED PULSES DISTANT\n GI POS B/S NOTED FIRM DISTENDED U/O QS PLEASE SEE I/O SHEET FOR DETAILS ON ALL DRAINS AND DRAINAGE NON TENDOR LG SCOTUM ELEVATED FOR COMFORT AND DRAINAGE\n RESP CLEAR DIM AT BASES NORMAL ABG\n IV NTG IN PROGRESS FOR BP NO HIGHER THAN 140 SYS\n PLAN HEALING\n" }, { "category": "Nursing/other", "chartdate": "2194-01-05 00:00:00.000", "description": "Report", "row_id": 1311866, "text": "NEURO-ALERT/ORIENTED X3. PLEASANT & COOPERATIVE WITH CARE. VOICES CARES & CONCERNS.APPRPPRIATE CONVERSATION. FOLLOWS ALL COMMANDS. . DOING ANKLE PUMPS. MEDICATED WIT 1MG DILAUDID Q3-4HR FOR C/O DULL PAIN. OOB TO CHAIR FOR 4HRS.\n\nCV- NSR.RATE CONTROLLED.NO ECTPY.NTG GTT + ATC LOPRESSOR & HYDRALAZINE TO KEEP SBP <140. 3+ PERIPHERAL AND SCROTAL EDEMA. +pp x4. ANTERIOR RT THIGH SEEPING COPIOUS FLUID AT INCISION SITE. DSD CHANGED PRN,\n\nRESP- 2LNC-> RA. SATS=96% LSC CLEAR.\n\nGI- ABD FIRM DISTENDED. + BS. G& D TUBES TO GRAVITY DRG GASTRIC FLUID. J- TUBE CLAMPED. JP WITH SMALL AMT S/S DRG. TPN FOR NUTRITION.\n\nGU- FOLEY DRG CLEAR AMBER URINE. 10MG IVP LASIX X1. DIURESED LARGE AMT URINE.\n\nENDO-GLUCOSE CONTROL MUCH BETTER TODAY NOW THAT TPN HAS INSULIN IN IT. GLUCOSE LEVELS 177/147. COVERED WITH SSC.\n\n SON AND WIFE UPDATED BY PHONE.\n\nPLAN- NTG GTT DCD.KEEP SBP < 140.RT THIGH DSG CHANGES PRN. DILAUDID PRN FOR PAIN MANAGEMENT.MONITOR ALL DRG BAGS.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-30 00:00:00.000", "description": "Report", "row_id": 1311848, "text": "N: A&O X 3, MAE, FC, Dilaudid PCA pt states good effect w/abd. pain . Skin/sclera slightly jaundiced. Afebrile.\nCV: Monitor shows NSR 80's with occas. tachy low 100's. RIJ cortis with SG. see flowsheet for detail vs. Anasarca. lytes repleted/KCl and Calcium scale ordered. HTN controlled with Lopessor 10 mg q4h and Hydralazine q4H PRN with goal SBP =< 120. LRAline intact/good waveform. LAC 18g patent with lactated ringers at 75 cc/hr. Right medial thight with large incision well approx./staples, DSD clean/intact. Pedal pulses/post. tib pulses palpable.\nR: half mask to maintain sats >= 92%. LS clear.\nGI: Jtube clamped with TF off. Gtube to gravity draining small amt dark green liquid. Abd. soft, ND, tender. BS hypo X 3 and absent in LLQ. Abd. incision well approximated with staples intact, DSD clean/dry. DSD around G/J tubes, dry/intact. Fecal incont. bag draining small amts brn liquid. GI consult w/sigmoidoscopy to be done today for severe abd. pain throughout night.\nGU: Foley draining adeq. amts clear/amber urine. Scrotum large/edematous.\nSkin: red rash d/t ceftriaxone allergy. rash unchanged throughout day. buttocks with breakdown on coccyx and bilat/reddened/chaffing with slight sanguinous drainage.\nPlan: continue monitor s/s infect./bleeding/bowel ischem./stool/lytes/fluid, maint. stable BP, pain mgmt., IV antibiotics, skin care, reorient as needed, pulm. toilet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-30 00:00:00.000", "description": "Report", "row_id": 1311849, "text": "Procedure: at approx 1330 pt sigmoidoscopy, pt given 50 mcg Fentanyl and 1 mg Versed. Tolerated procedure well. Mucosa found pink/intact. may have slight bleeding following procedure, none noted. Fecal bag intact, pt resting comfortably.\n\nPt given prn hydralazine 10 mg for SBP 120-130 with good effect. NAD, will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-31 00:00:00.000", "description": "Report", "row_id": 1311850, "text": "neuro: Awake and alert. C/o abdominal pain despite pca use. more attempts and pt. is locked out. Pain is at rest and pt. noted to be moaning. H.O. Called. Supplemental fentanyl 25mcg x1 ordered and given for breakthrough pain.\n\nCv/resp vss bp stable. increases when in pain. hydralazine x1 for syst>120. getting metropolol around the clock. cco readings wnl. svo2 readings wnl. o2 70% open face tent. o2 sats mid 90's.\nLungs clear/diminished.\n\ngi/gu foley qs uop amber colored. fecal bag intact small amt of stool noted to be in the bag. Gtube to gravity. minimal amt of drainage noted.J tube clamped. no feedings over night. pt. is npo.\n\ninteg: abdominal dsg and right leg dsg D+I. Coccyx reddened. Pt. turned s-s. body rash less red and bright. no c/o itch. right foot edema noted. Right leg elevated on 2 pillows.\n\nPlan: Continue pain management. ? increase PCA dosage? Reassess for tube feedings. monitor hemodynamics. esp BP control.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-31 00:00:00.000", "description": "Report", "row_id": 1311851, "text": "S/P aortic-enteric fistula repair, removal of AAA graft with bifem. bypass. Mult. organisms cultured from graft and pt remains on vanco, aztreonam, flagyl, & flucon. Pt afebrile. Random vanco sent today with result of 13.7. Pt had > pain throughout night and did not get relief from PCA dilaudid so a CT with contrast performed and benign for leaks/ obstruction/abscess; however ? bilat pleural effusions and some ascites. Right cortis/CCO removed/RIJ rewired with triple lumen now intact. Pt tolerated well. SBP labile throughout day, controlled with Lopressor 10 mg q4h and hydralazine 10 mg q4h. Additional 5mg Lopressor given at 1000. Pt with > anxiety throughout day d/t procedures. Seen by SW today. Wife in contact, son ? visit tonight. Pt currently resting comfortably, pain and states \"feeling better.\"\n\nN: alert/oriented x 3, MAE, FC, slera jaundiced. Afebrile. PCA dilaudid 1.25/hr. pt needs freq. reminding to press button. Pain throughout day constant at 3-4 and approx. 1700 stated .\n\nCV: Monitor shows NSR without ectopy, HR 80's - 90's. RIJ triple lumen with KVO. CVP 3-7. LR A-line intact with good waveform. HTN, see above. LFA 16 with some redness, LAC 18 with LR at 75cc/hr. KCl repleted 20 meq this a.m. DP/PT easily palpable, brisk cap refill, skin warm/dry, +2 edema of extremities. Left leg DSD intact without drainage. Groin draining small to mod. serous dsg reinf. Coccyx with abrasion/redness OTA.\n\nR: Pt sats mid 90's on RA. Upper lobes clear and dimin. in bases.\n\nGI/GU: Foley clear/amber, adeq. Fecal bag with small amt. liquid brn stool. BS hypo x 3, absent LLQ. Abd. incision approx. with staples, clean dry, OTA. Gtube/Jtube dressing intact/no drain. Jtube clamped, Gtube draining gravity dark green liquid. Stomach/Duodenum junct. sutured for bowel rest. NO MEDS/NOTHING PER G TUBE.\n\nSkin: red rash on upper body resolving ? ceftriaxone given OSH.\n\npoc: Monitor/control HTN/pain/infection/pulmonary/lytes. skin care. Maintain right leg elevated on 2 pillows.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-31 00:00:00.000", "description": "Report", "row_id": 1311852, "text": "UPDATE TO 0700-1900 NOTE: PT started on daptomycin for VRE. d/t start TPN this evening. Ordered at 1900 by NP.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-06 00:00:00.000", "description": "Report", "row_id": 1311867, "text": "Focuses Nursing Note\nPlease see carevue flowsheet for further details\n\nNeuro: Pt pleasant, cooperative. A/O x3. Moves all extremities equally. Medicated for abdominal pain generalized and in LLQ. Dilaudid 2mg q3hr therapeutic. No adverse effects.\n\nResp: NO SOB, SPO2 94-98% room air.\n\nHemo: NSR 70s-80, no ectopy. SBP 135-145 at best, 155-165 when in pain- off NGT gtt. Lopressor q4hr, hydralazine q6hr ATC. Good u.o. self-diuresis- though wt unchanged at 76kg. Anasarca. Fluid balance at midnight -1350. Copious amt serous drainage from RLE incision, unable to quantify. Feet warm, +3 pedal pulses. K+ and Ca2+ repleted.\n\nGI: NPO. No/nv. Abd softly distended, bs present. J-tube clamped. G-tube/Duodenal tube to gravity, green/bilious. TPN at 65ml/hr.\n\nSkin integrity: No new areas of breakdown. Allevyne intact to coccyx. Body rash scaling/dry.\n\nPsychosocial: Emotional support ongoing to pt. S.O. called in am for update, notifies rest of family be email daily.\n\nPLAN: Cont to monitor BP, goal SBP 140. Replete electrolytes, diuresis and fluid balance goal per vascular team. NPO, TPN. Antiobiotics x 4 classes. Pain control with Dilaudid. OOB to chair and encourage C/DB, IS hourly. Aggressive skin care. Emoiotnal support and education on plan of care ongoing.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-29 00:00:00.000", "description": "Report", "row_id": 1311845, "text": "pt weaned to extubation this shift without incidence. cough weak and some hypoxia on ABG. plan is to monitor and continue with pulmonary toilet.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-29 00:00:00.000", "description": "Report", "row_id": 1311846, "text": "SUN 7A-7P\nROS:\n\nNEURO: A/0X2 HAS DIFFICULTY WITH YEAR, EASILY REORIENTED. PUPILS UNEQUAL(L>R) BRISK & REACTIVE. ANXIOUS & WORRISOME. MAE, FOLLOWS COMMANDS. INCISIONAL PAIN CONTROLLED WITH FENTANYL GTT. AFEBRILE. VISIT TODAY FROM S.O.\n\nCV: NSR 50-90S. NO ECTOPY. PO METOPROLOL STARTED THIS AFTERNOON. CCO PA CATHETER IN PLACE, SVO2>65 CI>2.7 SEE CAREVUE FOR FILLING PRESSURES. NTG GTT STARTED, GOAL SBP 100-120. PALPABLE PULSES TO LLE; DOPPLERABLE TO RLE. HCT SLOWLY TRENDING DOWN FROM 30 TO 27.5 THROUGHOUT COURSE OF DAY. SQ HEPARIN FOR DVT PROPHYLAXIS. COMPRESSION SLEEVE TO LLE.\n\nRESP: EXTUBATED @ 1130 TO 50% FACE TENT. POST EXTUBATION PAO2 75; FIO2 ^ TO 70%. 02SAT >96%. LS CL. WEAK NON-PRODUCTIVE COUGH.\n\nGU/GI: FOLEY TO GRAVITY ADEQUATE AMBER HUO. ABD SNT (+)BS. REPLETE WITH FIBER TF STARTED VIA JTUBE @10CC/HR. G TUBE TO GRAVITY WITH BILIOUS DRAINAGE. MULTIPLE LIQ BROWN STOOL, GUIAC (-).\n\nENDO: GLUCOSE COVERAGE PER RISS PROTOCOL.\n\nSKIN: FULL BODY RASH, IV BENADRYL PRN. COCCYX RED, SKIN BREAK DOWN NOTED, ALOE VESTA CREAM APPLIED.\n\nPLAN: CONTINUE TO MONITOR HEMODYNAMICS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-30 00:00:00.000", "description": "Report", "row_id": 1311847, "text": "CVICU NPN\nO: ROS\nNeuro: Fentanyl gtt for pain. Pt had increased abd pain, LLQ around Jtube and became tachypneic, tachy and htn, moaning in pain. Fentanyl gtt increased w/ little effect. Pt given iv dilaudid and is now on dilaudid pca w/ gd effect. Needs reminding to use pca. A&O x2-3 and easily reoriented. Occasionally seeing things in rm and agitated, calms with conversation. MAE and following commands.\n\nCV: Persistent htn despite pain control and increased NTG to 5mcg/kg/min w/ SBP remaining > 140-150. Started iv lopressor and hydralazine w/ gd effect, NTG weaning now at 3mcg/kg/min. HR 80-100's nsr, no ectopy. Pedal pulses palpable.\n\nResp: Remains on face tent now on 100% to maintain 02sat >92%. Stable abg. SRR 16-25. LS clear, nonproductive cough.\n\nRenal: Adequate u/o. IVF at 75cc/hr. Body balance +3liters at mn. Skin and urine icteric. Metabolic alkalosis noted. T bili up to 5.0.\n\nGI: Increased LLQ pain surrounding Jtube. TF stopped. G-tube to gravity, Jtube clamped. Gastrografin KUB done due to pain w/ feedings. Results negative for leak. Maintained NPO overnight. Incontinent of lge amt liquid stool. Fecal incontinence bag applied and patent.\n\nHeme: Stable.\n\nID: Afebrile. WBC 17.7 Cont on multiple abx.\n\nSkin: Total body red rash noted, ?etiology. Given benadryl x1. Reddened around coccyx d/t liquid stool. Fecal bag applied and cream to exposed areas. Midline and RLE incisions wminimal dnge. Covered w/ dsd.\n\nSH: No family contact .\n\nA: ?etiology of increased pain. No evidence of leak. Improved control w/ dilaudid. HTN improved w/ hydralazine and lopressor.\n\nP: Cont to monitor and support systems. Cont dilaudid pca for pain. Reorient frequently. Cont hydral and lopressor. Wean ntg as tolerated.\nPulm toilet. Maintain npo. Monitor stool output, fluid balance and replete lytes. Cont iv abx. Skin care. PRN benadryl for rash. Cont pt and family support.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-04 00:00:00.000", "description": "Report", "row_id": 1311863, "text": "NEURO: alert, oriented to person and . states he is outdoors, bed is a \"spinning wheel\". PERRL. MAE weakness in all extremities. inconsistent reports of pain in back (unable to specify location) and abd. medicated with dilaudid for turns and dressing change.\nCV: sinus rhythm rare pvc noted. K repleted. sbp goal <140 IV lopressor, IV hydral, NTG gtt. 130's-143 most of noc. +peripheral and scrotal edema, +palpable pedal pulses. weeping serous fluid from suture lines/through tissue of arms/legs.\nRESP: coarse lungs bilat. good cough effort, rarely cooperative with cough and deep breathe. expectorating yellowish, thick sputum. face tent 50%. sats 95-98%\nGI/GU: abd firm and distended G, D tubes to gravity draining bilious, J tube clamped JP drain with serosang drainage. NPO. No meds or flushes in G, J, or D tubes. +hypoactive bowel sounds above tubes, no bowel sounds below. On TPN.\nENDO: CSRU RISS, steroid IV.\nID: afebrile, on aztreonam, flagyl, daptomycin, fluconazole.\nSKIN: midline abd incision with retention sutures w-->d packing and softsorb dsd G, J, D tubes sites CDI with dsd. R thigh staples with copious serous drainage softsorb and chux changed frequently through noc. allevyn on coccyx intact. moved to kinair bed.\nLINES/ACCESS: triple lumen CVL, leaking so changed over wire and confirmed with CXR.\nPSYCH/SOC: no calls this shift.\nA/P: hypertensive, resp stable, poor skin integrity. continue antihypertensive and antibiotic regimens as ordered, skin care, pain control, pulm hygiene. remain NPO. nothing per G, J, D tubes.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-04 00:00:00.000", "description": "Report", "row_id": 1311864, "text": "NEURO-ALERT/ORIENTED X2-3 PLEASANT/COOPERATIVE WITH CARE.APPROPRIATE WITH CONVERSATION.PERLA. MAE. CONSISTANTLY FOLLOWS COMMANDS. ANKLE PUMPS Q3H- 10 REPS EACH. MEDICATED WITH 1MG DILAUDID IVP Q4-5 FOR C/O CONSTANT \"DULL\" BACK PAIN.\n\nCV- NSR. RATE CONTROLLED. RARE PVC. NTG GTT/ATC LOPRESSOR & HYDRALAZINE TO KEEP SBP <140. + PERIPHRAL & SCROTAL EDEMA. + PALP. PULSES X4. RT ANTERIOR THIGH WITH STAPLES WEEPING COPIOUS AMOUNTS SEROUS FLUID DSG CHANGES( AQUACEL COVERED WITH 4X8 AND SOFTSORB Q4H. ABD DSG (W->D) INTACT.\n\nRESP- 50% OFM ->3LNC. SATS MAINTAINED @ 98%. LSC ANTERIOR, DIM BASES.\n\nGI- ABD.FIRM & DISTENDED. HYPERACTIVE BS.PASSING FLATUS. J-TUBE CLAMPED AND FLUSHED(PER TEAM X1 TODAY) G & D TUBES DRG BILIOUS FLUID.TPN FOR NUTRITION.\n\nGU- FOLEY DRG CLEAR AMBER URINE.\n\nENDO- FINGERSTICK GLUCOSE LEVELS COVERED WITH RISS. LEVELS 170-177 ALL DAY. INSULIN REQUESTED AND ADDED TO TPN.\n\nSOCIAL WIFE AND DAUGHTER INTO VISIT AT SEPERATE TIMES. PT APPEARED PLEASE WITH COMPANY.\n\nPLAN-CONTINUE TO KEEP SBP <140. RT THIGH DSG CHANGES Q4H/PRN.PAIN MANAGEMENT WITH DILAUDID Q4HR. MONITOR ABD DRAINS FOR PATENCY AND DRG.\nQUADROUPLE ABX TX. PULM HYGEINE. ANKLE PUMPS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2194-01-13 00:00:00.000", "description": "Report", "row_id": 1311873, "text": "CVICU Progress\nS/O: Neuro: Cisatracurium stopped, pt opening eyes but no other response. Remains on fentanyl and midazolam infusions.\n CV: Attempted to wean norepinephrine, but pressure down and needed to increase to 0.06 mcg/kg.\n Resp: No vent changes.\n Renal: Urine output 25-90 ml/hr. Creatinine up to 2.2. Lactated ringers at 100ml/hr.\n Heme: Lg amt melena loose stool X 2. Hct stable at 30.\n ID: Afebrile, multi antibiotics.\n GI: Stool as above. Pantoprozole daily. NGT, Gastric tube, jtube, 2 jps, back drain. TPN started.\n Endo: Glucose up to 91. 32 units of insulin in TPN.\n Skin: coccyx pink but not broken. On airbed. Skin very dry.\n Lines: still with 2 art lines, multi-lumen, peripheral angio.\n Family: Daughter called.\nA: Old blood from GI tract. Still dependent on norepinephrine. ?Glucose stabilizing. Renal status worsening.\nP: Watch glucose with insulin in TPN. If BP tolerates, decrease lactated ringers to total 100 ml/hr with TPN. Turn every 2 hours, inspect coccyx. All supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-14 00:00:00.000", "description": "Report", "row_id": 1311876, "text": "Neuro: patient wean off fentanyl and versed since :30 pm today. patient opens eyes but no other response. afebrile.\n\nCV: Pt remain hemodynamic stable, blood pressure remain unchanged since wean off levophed.\n\nResp: Pt remain vented, tol vent changes, see sheet for details sats 98 to 100%. possibly extubated in am.\n\nGI: no bm today, ngt, gastric tube, j tube, 2 JP's back drain, pt cont on TPN, no BM today, protonix daily, monitor for s/sx of asp. blood glucose 135 covered with 3 units of reg insulin per SSI. and TPN contain 32 units of insulin.\n\nGU: Pt putting adequate urine output, creatine 1.0 today.\n\nID: pt remain afebrile, multi antibiotics.\n\nSkin: pt on Air bed, coccyx pink, no open area noted, right leg still oozing, requires multiple dressing changed.\n\nPlan: to remain vented tonight and attempt to extubate pt in am. monitor renal function, maintain hemodynamic stable follow up with vascular. monitor glucose closely, turn and reposition every 2 hours, and maintain safety precaution. and continue to provide support to pt and family member.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2194-01-15 00:00:00.000", "description": "Report", "row_id": 1311877, "text": "Resp Care: Pt continues intubated #7.5 oett secured @ 23 @ lip and on ventilatory support with minimal psv maintaining Vt 500's with Ve 7-9 L, good abg; bs crackles bilat, sxn thick white secretions, rsbi 40, will cont slow wean till ms clears.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-24 00:00:00.000", "description": "Report", "row_id": 1311836, "text": "Nsg admit note\n63 yo man admitted from OSH he had increasing central lower back pain x 1 month worse with position changes from sitting to standing, radiating occasional to right knee. At OSH he had a fever of 101.4 and was hypotensive 90/70, his wbc 20.6 with 6% bands and he was given vanco. His CT findings are concerning for recurrence of an infectious process and for aorto enteric fistula. PMH he had mycotic aneurysm measuring 3.5x4.7cm 7x7/2cm along with L2-3 discitis and osteomyelitis posterior to AAA and possible epidural abscess. He underwent EVAR across contained rutputre with persistent ?type IV leak on and then underwent definitive resection of ruptured mycotic aortic aneurysm. repair of aneurysm with tube graft, L2-3 vertebrectomy and arthrodesis at . Abdominal cultures and lumbar puncture fluid grew pansensitive E coli but tissure grew nothing. HTN, Hyperlipidemia, etoh abuse, b/l inguinal herniorrhaphy.\nSocial is divorced his son is his HCP no number available he does not know his phone number. Former etoh abuse and smoking history. Allergies zoysn and ceftriaxone rash ? increase in LFT\na. Pleasant man alert and oriented x3, mae, fc. MRI done of spine results pnding. C/o of severe pain central back with activity given hydromorphone 1mg IV q 3 hrs prn with good results\nresp on room air o2 sats > 95% lungs clear\ncvs Hct 24 down from 29.9 tx with 2 uprbc bp 122/82 skin w+d pp+ IV d5.45 with 20kcl at 100cc qhr\nID wbc 9.45 first dose of aztrenam 1000mg IV given temp max 99.4\ngu voiding bun 21 cr .9\ngi npo except meds and ice chips abd soft bowel sounds + ast 125, alt 264\nendo not requiring ss insulin\naccess 2 18 g periph\na. prior mycotic aneurysm and spinal osteomyelitis, epidural abscess with intra abdominal graft and spinal bony graft now presents with fever, hypotension, leukocytosis, and severe central low bck pain ct concerning for recurrence of an infectious process and for aorto enteric fistula\np. pain control fentanyl patch and hydromorphone 1mg q 3 prn monitor hct, bp goal sbp 100-130/. monitor wbc, temp vanco and aztreonam await culture results\n\n" }, { "category": "Nursing/other", "chartdate": "2194-01-18 00:00:00.000", "description": "Report", "row_id": 1311894, "text": "0605AM EVENT NOTE.\n\nVENT ALARM RINGING OFF, RESP THERAPIST IN ROOM ATTENDING TO VENT (HIGH MINUTE VOLUME)PT MONITOR ALARMING HIGH HR WITH LOW BP.RN AND RT IN ROOM PT NON RESPONSIVE TO AGGRESSIVE STIMULI. HR/BP TRENDING DOWN. EYES ROLLED BACK IN SOCKETS.COLOR=JAUNDICE. RHYTHM=PEA. ACLS CODE BLUE INITIATED. SEE FLOWSHEET. PT AND ON HIGH DOSE LEVO AND EPI. RT PUPIL NOTE TO BE 6MM AND FIXED. PRESSURE BEGAN TO TREND DOWNWARD AGAIN. FAMILY NOTIFIED OF SEQUENCE OF EVENTS AND WISH TO WITHDRAW SUPPORT AND MAKE THIS PT A \"CMO\".\n" }, { "category": "Nursing/other", "chartdate": "2194-01-18 00:00:00.000", "description": "Report", "row_id": 1311895, "text": "o: CMO WITH FENTANYL. PT EXPIRED AT 0740. DAUGHTER NOTIFIED. SON AND DAUGHTER PHONED AND WISH NOT TO SEE PT. DAUGHTER WILL COME TO THE HOSPITAL TO COLLECT BELONGINGS. PRONOUNCED. ORGAN MEDICAL EXAMINER AND FAMILY CALLED. NO AUTOPSY PER FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-15 00:00:00.000", "description": "Report", "row_id": 1311878, "text": "Neuro: pt lethargic opens eyes but does not appear to focus. He does nod his head yes to some questions. Minimal movement of arms and legs seen but not to command. Pt has remained off all sedation.\nResp:On CPap 5 and IPS 5 all night tolerated well. Suctioned for scant amounts of thick white. Breath sounds clear.\nC/V: Aline waveform dampened and square in shap following cuff pressures which are 20-30 points lower. Started on LOpressor 5mg IV every 6huors tolerated well but has not helped BP very much. HO stated a BP under 150 is ok. CVP 10-14. Bladder pressure 14. Palpable pedal pulses. Pt has pitting edema in hands and legs.\nGI: NGT draining scant amounts of bilious. G tube also draining bilious no drainage from Jtube. NO bowel sounds heard.\nEndo: blood sugars treated with sliding scale.\nGU: adequate amounts of icteric urine.\nSkin: Incision clean small amount of old serous sangunious drainage from upper aspect of abdominal incision. Right leg incision draining large amounts of serous drainage. Duoderm intact on coccyx.\nID: pt continues on multiple antibiotics. to have gentamycin levels today.\nPain: pt grimaces when pressing on belly or moving in bed but sedation and pain medication on hold waitting for pt to wake up more.\nPlan: Continue wean possible extubation if wakes up more.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2194-01-15 00:00:00.000", "description": "Report", "row_id": 1311879, "text": "resp care\nremains intubated on psv 5/5/50%. tolerating well with stable ve,rr.sxning thick yellow sputum. sats stable. remains intubated due to mental status. refer to flow sheet for data.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-17 00:00:00.000", "description": "Report", "row_id": 1311890, "text": "cvicu update\nneuro/pain: pt did follow rare command this am. moved both feet to command. nodded \"yes\" to pain. fentanyl added. on propofol briefly this afternoon for procedure.\n\ncv: vs as per flowsheet. remains very edematous. extrems warm. plt to 61. HIT +. seratonin assay sent this afternoon. NSR 70-80's. hypertensive at times. lopressor, enalaptilat and hydralazine ordered, a couple of afternoon doses held r/t presumed OR vs procedure.\n\nresp: pt w/ mixed alkalosis but increased RR this am. placed on AC vent. fentanyl drip as above. sx x 1 for nothing, lungs clear bilat.\n\ngi: pt w/ increased dng from JP 1 (perianastomotic). JT feeds stopped this am ( not to resume at present). gastrografin prep given via gt. abd/pelvic Ct showing lg collection. both JP draining mod amts upon return to cvicu. plan made to return to CT for perc drain--> no collection to drain at that time. ngt to lwsx for min bilous, GT to gravity for min bilous. cont tpn. lyte repletion.\n\ngu: uop qs. lasix d/c. ivf 1:1 replacement to jp output if increases.\n\nskin: edema. duoderm to coccyx. stay sutures intact. rt thigh dsc intact, some serous dng. multi left abd drains intact, dsg change this am.\n\nid: temp increase to 101.6 this am. bc x2 and urine c&s sent. no sputum obtained. wbc wnl. cont on multi abx. genta dose decrease. due this pm.\n\nsocial: brother in. no other calls or visits.\n\nassess: increase dng from JP. ended up not requiring perc drain. ttemp though wbc wnl. remains gravely ill.\n\nplan: rescan \"in a couple days\". cont aggressive support. no feeds at this time. fluid replacement if JP output increses.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2194-01-18 00:00:00.000", "description": "Report", "row_id": 1311891, "text": "REspiratory Care\nPt remains intubated on vent support. AM RSBI 27. ABG WNL with hyperoxia. W/O need for Sx BS clear. Weanined to PSV 5/5.\nPlan: Wean to extubation when stable.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-18 00:00:00.000", "description": "Report", "row_id": 1311892, "text": "Respiratory Care\nVent alarming at 06:00, High respiratory rate. BP low , PEA arrest CPR began.\nCurrently on A/C ventilation see care vue for details\n" }, { "category": "Nursing/other", "chartdate": "2194-01-18 00:00:00.000", "description": "Report", "row_id": 1311893, "text": "neuro- intubated/sedated on fentanyl gtt. non-responsive to voice. pupils r=3ml l=4mm bilaterally brisk. facial grimacing accompanied with htn when repositioned & with dsg changes. 0430 AM: pt alert,tracking & focusing on RN. direct eye contact & following commands.\n\ncv- nsr hr stable. htn. continues on lopressor,hydralazine and enalapril otc.afebrile. wbc down. abx coverage includes daptomycin,gentamycin,flagyl and fluconazole.skin w/d. palp. pulses.\n\nresp- simv vent support. abg wnl.hyperoxemia. lsc-> course. no secretions when sxd. switched to cpap this am (0500) tolerating it well. rsbi=49.\n\ngi- abd soft. BS absent->present->absent. no stool. g-tube & ngt drg bilious secretions. jej-tube clamped. JP #1 drg mod amt reddish brown secrtions. JP #2 drg scant amt blood secretions. d-tube with no drg. TPN via triple lumen. ivf D5 1/2 NS with 20meq kcl /1000ml infusing cc/cc gastric output.\n\ngu- clear yellow urine. adequate hourly output.\n\nlabs- no repletins needed. glucose level covered with ssci.\n\npain- facial grimacing with turning or dsg changes. fentanyl gtt @ 150mcg/hr. with intermittent 2cc/bolus's.\n\nplan- continue to monitor hemodynamics and review of systems. wean to extubate if remains stable. monitor abdominal drains and gastric output.\n\ngu-\n\n" }, { "category": "Nursing/other", "chartdate": "2194-01-16 00:00:00.000", "description": "Report", "row_id": 1311884, "text": "Resp. care note\nPt remains intubated and vented on PSV settings as per resp flowsheet. No vent changes made this shift. BS coarse at times, sxn for thick yellow secretions in AM, decreased amount and less purulent looking in afternoon. No ABG's so far this shift. Cont current support.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-16 00:00:00.000", "description": "Report", "row_id": 1311885, "text": "lethargic,not tracking with eyes or following commands. does move arms L > R as if to reach ett during suctioning or mouth care but to weak to complete act.lt. wrist immobilizer placed for safety. occasional movement of lt. foot noted.grimaces to pain.HIT screen positive,heparin removed from tpn & rij multilumen changed over a wire. tip sent for culture.bilat. effusions on cxr,continues with brisk diuresis on lasix. lower exremity edema improving.continues with whitish mucoid stool. trophic tube feeds continue via j tube.s.o. updated,see flow sheet.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-16 00:00:00.000", "description": "Report", "row_id": 1311886, "text": "more alert past hour,reaching up to mouth repeatedly,bilat. wrists holders applied.increasingly hypertensive with increased alertness,hydralazine increased. attempting to maintain sbp < 160.remains hypokalemic with brisk huo,mod. amount gastric dng. generally continuous k+ replacement.jp # 1 with moderate dng dark reddish-green. passing small amounts gelatinous whitish stool with bloody streaks.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-17 00:00:00.000", "description": "Report", "row_id": 1311887, "text": "RESP CARE: Pt remains intubated/on vent on settings per carevue. No changes this shift. Lungs coarse rhonchi bilat. Sxd thick white. AM RSBI-133.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-17 00:00:00.000", "description": "Report", "row_id": 1311888, "text": "NPN (NOC):\n\nRESP: PT REMAINS INTUBATED. CURRENT VENT SETTINGS: PS 10 X 5 PEEP X 50%. RR HAS BEEN ~ 30 PER MIN SINCE ~ 1 AM. HE IS SPIKING A TEMP (99.5 AT MN TO 100.6 PRESENTLY). VT'S 300'S TO 400'S, ABG:109/27/7.58/26/5. PLAN TO DECREASE PS. BS'S CLEAR. SX'D FOR MINIMAL SECRETIONS.\n\nCV: HEMODYNAMICALLY STABLE . SBP'S WELL0 CONTROLLED ON VASOTEC/HYDRALAZINE/METOPROLOL.\n\nNEURO: OPENS EYES BUT DOES NOT COMMUNICATE OR FOLLOW COMMANDS. DOES NOT APPEAR TO HAVE PAIN AND HAS NOT BEEN RESTLESS SO NO SEDATIVES GIVEN.\n\nGI: NGT TO LCS AND G-TUBE TO GRAVITY PUT OUT ~ 100 CC'S BILIOUS MATERIAL TOTAL. INC OF LOOSE MUCOUSY STOOL X2.\n\nF/E: NEGATIVE ~ 6 LITERS BY MN. TOTAL OF 60 KCL AND 2 AMPS CALCIUM GIVEN .\n" }, { "category": "Nursing/other", "chartdate": "2194-01-17 00:00:00.000", "description": "Report", "row_id": 1311889, "text": "Resp. care note - Pt. remaines intubated and vented, transffered to CT and back to CVICUA x 2 without incident.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-15 00:00:00.000", "description": "Report", "row_id": 1311880, "text": "neuro- ALL sedation of since @ 1200. pt awake but does not focus.continual \"blank stare\" at ceiling all shift. no startle reflex. does not follow commands or move any extremities. facial grimacing with dsg changes or turning pt.occasionally nods head yes to question asked. perla 4mm/brisk.\n\ncv-nsr no ectopy. uncontrolled htn. continues on lopressor atc with increase in dose to from 5mg q6h to 10mg q6h. started on enalapril & hydralazine. cuff pressure 30pts lower than a-line. (dampened and squared) generalized pitting edema.\n\nrsp-cpap 50% 5/5.lsc. dim left base. rr=18-22. tv=350-500. remain intubated until neuro status imporves.\n\ngi- abd softly distended. absent bs. tube feed started at 10cc/hr ( no increase in dose) via j-tube. continues on TPN. abdominal incision with retention sutures leaking serous fluid. gastric & duodenal drains to gravity.\n\ngu- large diureses after 20mg lasix ivp x1. pt 1liter (-) today. adeq. hourly u/o.\n\nlabs- k+ pending. glucose level 126. covered with ssi.\n\npain- facial grimacing with dsg changes or repositioning. unable to medicate with narcotic d/t neuro status.\n\n\n\nplan- control htn. monitor resp/gu status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2194-01-16 00:00:00.000", "description": "Report", "row_id": 1311881, "text": "Neuro) Pt. opens eyes spont. Does not track or focus. Nods and shakes head to questions. Moves both upper extr. L>R but not to command. No spont. movement of lower extr. noted and no movement when stimulated.\n\nCV) BP management remains an issue. Increase in Lopressor with the addition of Hydralizine q6. SBP down to 130's is the lowest after meds. SBP kept <160. Skin pink, warm and dry.\n\nPulm) Pt. slightly tachypneic as he wakens more. IPS up to 12cm due to high minute vent > 11L/min. RR 30. ABG resp. alk. Minimal ETT secretions.\n\nGI) Pt. being fed via JEJ tube, No stool, no bowel sounds. NGT and G-tube with bilious drng.\n\nGU) great diuresis from Lasix. many kcl repletions for K+, <3.7.\n\nSkin) weeping serous fluid from incisions and tiny skin pores.\nNo active bleeding from any tubes or drains.\n\nHeme) Hct at 29.\n\nEndo) insulin protocol for pt. followed. Insulin in TPN also.\n\nPlan) continue diuresis. antibiotics. monitor neuro status as pt. awakens more.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-16 00:00:00.000", "description": "Report", "row_id": 1311882, "text": "Resp Care: Pt continues intubated #7.5 oett secured @ 23 @ lip and on ventilatory support with psv, up to +12 for increasing tachypnea/decreasing Vt maintaining Ve 11-13 L with persistent resp alkalosis; bs crackles bilat, sxn thick white secretions, rsbi 118 as compared with 40 yesterday, will cont to attempt wean neuro picture clears.\n" }, { "category": "Nursing/other", "chartdate": "2194-01-16 00:00:00.000", "description": "Report", "row_id": 1311883, "text": "neuro- objectively apprears to be more lethargic with no interaction or focal tracking at all. no spontaneous movement or startle reflex seen.+ cough with ett sxing.rt pupil<lt pupil bilateral brisk reaction.\n\ncv- htn more controlled on lopressor/enalapril and hydralazine. hr nsr/vea noted d/t large diureses from lasix. k+ repleted prn.\n\nresp- cpap 50% 5/10 tv=350-400. sats=100%. lsc,dim at base becoming rhonchorous in afternoon.sx thin white sputum.\n\ngi- tube feed at goal of 10cc/hr. via jej tube. g& d tube to gravity, JP x2 to bulb sx. stooling mucoidy white/clear stool. ( loooks like tube feed and TPN. increase dark blood drg from JP #1 since feeding started.\n\ngu-diureseing large volumes clear yellow urine from20mg ivp lasix .\n\nlabs- K= pendig.\n\npain- facial grimacing with turning or dsg changes.\n\nplan- monitor vs/resp/renal/gi/gu systems. triple abx coverage. dsg changes porn.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-24 00:00:00.000", "description": "Report", "row_id": 1311837, "text": "UPDATE\nCV: NSR 80'S, NO ECTOPY. SBP 130-140'S. EXTREMETIES /DRY. SL RASHY REDNESS ABOVE LLA PERIPH IV SITE; SITE PAINFUL WHEN IV FLUSHED. NEW L WRIST AREA PERIPH IV INSERTED AND PAINFUL ONE D/C'D. TWO UNITS TOTAL PRBC TRANSFUSED SINCE PT ADM. REPEAT HCT PENDING.\n\nRESP: CRACKLES L BASE EARLIER A.M., NOW LUNGS CLEAR. SPO2 94-98% ON RA, RR WNL.\n\nNEURO/COMFORT: A&O, VERY ANXIOUS AND APREHENSIVE THIS A.M. AFTER TALKING TO VASCULAR ATTENDING ABOUT POSSIBLITY OF INFECTED AAA GRAFT. REASSURANCE GIVEN AND PT'S SIGNIFICANT OTHER AND UPDATED BY R.N. AND PT AFTER WHICH HE FELT BETTER. DILAUDID PRN PAIN BUT PT STILL HAS # PAIN W/ MOVEMENT(# @ REST), PRIMARILY IN LOWER BACK. FENTANYL PATCH STARTED BUT PT SAYS THAT HISTORICALLY IT HASN'T WORKED FOR HIM.\n\nG.I.: SIPS H2O W/ MEDS.\n\nG.U.: ADEQ AMTS BY VOID.\n\nA/P: PT SCHEDULED FOR CONTRAST CT, VEIN MAPPING AND BRACHIAL PRESSURE EVAL FOR THIS AFTERNOON. KEEP NPO UNTIL AFTER CT RESULTS. PLAN TO START PCA FOR BETTER PAIN CONTROL. CONT ABX, TELEMETRY. WILL TRANSFER TO VICU WHEN BED AVAILABLE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-27 00:00:00.000", "description": "Report", "row_id": 1311838, "text": "PT ARRIVED TO CVICU-B AT 18:30 ON A NTG DRIP. PROPOFOL AND FENTANYL STARTED AS PT MOVING IN BED WITH BP CLIMBING. LABS SENT. CCO RECAL. R FOOT ELEVATED ON 2 PILLOWS. LR AT 150. R PUPIL > THAN L, 3CM VS 2CM. ANESTHESIA INFORMED, CVICU TEAM NOTIFIED. J AND G TUBE TO GRAVITY. NGT CURLED IN MOUTH, VASCULAR CALLED TO REINSERT.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-28 00:00:00.000", "description": "Report", "row_id": 1311839, "text": "NEURO: sedated on propofol and fent, lightened for neuro check MAE, followed commands to move fingers/toes. R pupil slightly larger than L pupil both briskly reactive. towards end of shift more lightly sedated on same dose, opens eyes to stimulus and localizes pain.\nCV: sinus rhythm 60's-70's. SBP goal <120. most of noc sbp 90's-110's brief drop to 70's with hct drop to 26.8 transfused with 2 PRBC. CI 2.5-3.2 SVO2 68-73 with drop to 58 with turns in bed. recovers quickly. cco recal'd for ?false high outputs >5 thermodilution checked to confirm cco accurate. cardiac enzymes trended one more set due 0800. lactate trending down. pedal pulses palp.\nRESP: intubated SIMV stable ABG. sats 98-100%. lungs sound clear in upper fields, bases with intermittent coarseness. suctioned for trace yellow thick sputum.\nGI/GU: NGT removed by vascular. G/J in place draining to gravity yellow/brown drainage. +bowel sounds had liquid brown BM x1. NPO. no meds per G or J tube. foley with clear yellow urine.\nENDO: blood glucose treated with CSRU sliding scale. stress dose steroids.\nID: on vanco, aztreonam, fluconazole. vanco level sent.\nSKIN: back/buttocks intact. Abd incision with staples. on turning in bed sudden large amount of serosang drainage. vascular eval' straps and soft-sorb pad for frequent saturation with serosang drainage. G/J insertion sites CDI. dsd changed. pt on air mattress overlay.\nPSYCH/SOC: no calls this shift.\nA/P: hemodynamic instability improving post transfusion. resp stable. monitor hct post transfusion, #3 set cardiac enzymes and lactate due 0800. ?wean to extubate. skin care. to remain NPO, no meds by G/J tube.\n" }, { "category": "Echo", "chartdate": "2193-12-30 00:00:00.000", "description": "Report", "row_id": 83996, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Hypertension. Left ventricular function. Right ventricular function.\nStatus: Inpatient\nDate/Time: at 12:22\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n63 years old for redo aortofem BPG secondary to infected aortic graft.\nNormal LV systolic function, patient tolerated the suprarenal clamp without\nany problems.\nVp 45 cm/sec. It decreased with the suprarenal clamp to 34cm/sec, came back to\nbaseline after the clamp came off. E/E' 12, with the clamp it went upto E/E'\nto 15.7 and came back to normal after the clamp was off.\nLEFT ATRIUM: Normal LA size. All four pulmonary veins identified and enter the\nleft atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Overall normal LVEF (>55%). Transmitral Doppler E>A and TDI E/e' <8\nsuggesting normal diastolic function, and normal LV filling pressure\n(PCWP<12mmHg).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. No RV mass/thrombus.\n\nAORTA: Normal ascending aorta diameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. Three aortic\nvalve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Overall left ventricular systolic function is normal\n(LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic\nfunction, and a normal left ventricular filling pressure (PCWP<12mmHg). The\nright ventricular cavity is mildly dilated. There is no mass/thrombus in the\nright ventricle. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. There are three aortic\nvalve leaflets. The mitral valve leaflets are mildly thickened. Mild to\nmoderate (+) mitral regurgitation is seen.\n\n\n" }, { "category": "ECG", "chartdate": "2193-12-27 00:00:00.000", "description": "Report", "row_id": 227685, "text": "Sinus rhythm. Low voltage in the limb leads. Short P-R interval without\nany other evidence of pre-excitation. Prolonged QTc interval. Compared\nto prior tracing of the rate is slower. Limb lead voltage is lower and\nQTc interval is more prolonged.\n\n" }, { "category": "ECG", "chartdate": "2193-12-27 00:00:00.000", "description": "Report", "row_id": 227686, "text": "Sinus rhythm. Short P-R interval without evidence of ventricular\npre-excitation. Compared to prior tracing of no change is seen.\n\n" } ]

[ { "category": "ECG", "chartdate": "2189-11-11 00:00:00.000", "description": "Report", "row_id": 153984, "text": "Sinus tachycardia\nLeft bundle branch block\nSince last ECG, faster rate\n\n" }, { "category": "Radiology", "chartdate": "2189-11-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 746195, "text": " 3:43 PM\n CHEST (PA & LAT) Clip # \n Reason: DECREASED SATURATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n DECREASED SATURATION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Low 0-2 saturation.\n\n CHEST, TWO VIEWS: Comparison . The patient has been extubated. There\n is orthopedic hardware overlying the lower cervical spine. The heart is normal\n in size without CHF. There is increased density with air bronchograms\n involving the left lower lobe, consistent with consolidation/collapse. There\n are small bilateral pleural effusions. There is no vascular congestion.\n Prominence of the right hilum mentioned in prior report is likely vascular.\n\n IMPRESSION: Left lower lobe consolidation/collapse. Small bilateral pleural\n effusions.\n\n" }, { "category": "Radiology", "chartdate": "2189-11-19 00:00:00.000", "description": "C-SPINE, NON-TRAUMA", "row_id": 746497, "text": " 8:39 PM\n C-SPINE, NON-TRAUMA Clip # \n Reason: POST OP NECK PAIN\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Post-operative neck pain.\n\n CERVICAL SPINE, THREE VIEWS: There is an anterior fusion plate, with fixation\n screws in the C3 and C7 vertebral bodies. There is a fibular graft replacing\n a portion of the bodies of C4 through C6. Alignment is within normal limits.\n There is diffuse prevertebral soft tissue swelling, consistent with recent\n surgery.\n\n" }, { "category": "Radiology", "chartdate": "2189-11-11 00:00:00.000", "description": "O C-SPINE (PORTABLE) IN O.R.", "row_id": 746008, "text": " 11:54 AM\n C-SPINE (PORTABLE) IN O.R.; C-SPINE (PORTABLE) IN O.R. Clip # \n Reason: ACF C3-7/CORPECTOMY ANT.C4-6\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ACF C3/7 corpectomy anterior C4/6.\n\n C SPINE PORTABLE IN OR: 2 films are submitted for interpretation. Film #1\n demonstrates some disc degenerative changes at C3/4, and . An anterior\n marker is seen at the disc space of C5/6 anteriorly. Film #2 demonstrates a\n plate extending from C3 to C7. Plate is fixated with 2 screws in the vertebral\n bodies of C3 and C7.\n\n" }, { "category": "Radiology", "chartdate": "2189-11-12 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 746091, "text": " 3:30 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: post op placement of screws c3 and c7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n post op placement of screws c3 and c7\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post-op placement of screws at C3 through C7.\n\n Comparison to the pre-op CT myelogram of .\n\n TECHNIQUE: Thin section axial images were obtained through the entire\n cervical spine. Sagittal and coronal reformatting was performed.\n\n FINDINGS: Since the previous examination, the patient has undergone\n corepectomy of C4 through C6. A bone graft has been placed between C3 and C7.\n There is an anterior fixation plate covering this area with fixation screws\n at C3 and C7. The superior extent of the graft material is placed\n asymmetrically, extending more to the left side than the right. There is more\n remaining native bone on the right side than the left. The more lateral\n fixation screw at the C3 level appears to traverse the foramen transverse\n ____.\n\n There is degenerative change of the left C2-3 facet joint and the left C7-T1\n facet. There is swelling of the prevertebral soft tissues related to recent\n surgery. Bulla are seen in the lung apices.\n\n IMPRESSION:\n\n S/P corepectomy with bone graft and fixation plate and screws fixing C3\n through C7 with asymmetric positioning of the graft, extending more to the\n left side than the right. There is progressively less bone remaining on the\n left side further superiorly in the surgical bed.\n\n" }, { "category": "Radiology", "chartdate": "2189-11-13 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 746135, "text": " 1:23 PM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # \n LAB RECONSTRUCTIONS\n Reason: post cervical fusion please perform CT angio to evaluate the\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n post cervical fusion please perform CT angio to evaluate the stsatus of left\n vertebral artery at c3 lavel with screw close proximity to artery at that\n level.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: year old woman with status post cervical fusion from C4 to\n C7.\n\n Noncontrast CT of the cervical spine demonstrates a screw in close proximetry\n with the left transfer foramen. patient is here for a CT of the cervical\n spine with contrast.\n\n The study is compared with a previous examination performed on .\n\n FINDINGS: The previous dictation was loss during the process of\n transcription, this is a redictation.\n\n Again noted are changes related to corpectomy of C4 through C6. A bone graft\n is again seen from C3 to C7. There is anterior fixation plate covering this\n area of fixation screws at C3 and C7. Again noted is a fixation screw at C3\n level which appears to be in very close proximityy with transverse foramen on\n the left and impinging on and in close proximity, with the left vertebral\n artery raising the suspicion of damage to the left vertebral artery. However\n there is flow noted in the left vertebral artery above this level . Again\n noted is prevertebral soft tissue swelling related to previous surgery. no\n other significant changes noted.\n\n IMPRESSION:\n\n Status post corpectomy with bone graft and plate and screw fixing C3 through\n C7. The screw at the C3 appears to be in close proximity with the left\n vertebral artery raising the suspicion of possible damage to the left\n vertebral artery. please correlate clinically\n\n No other interval changes noted.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2189-11-17 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 746292, "text": " 9:03 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: post op screw placement in c3 and c7\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n post op screw placement in c3 and c7\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Follow-up revision of cervical fusion.\n\n TECHNIQUE: Helical CT imaging of the cervical spine, with sagittal and\n coronal reconstructions.\n\n FINDINGS: Comparison is made to . There is an anterior fusion plate\n with fixation screws in the C3 and C7 vertebral bodies. Since the prior exam,\n the left screw at C7 has been removed from the transverse foramen and placed\n within the vertebral body.\n\n Again noted are left hemicorpectomies of the C4 through C6 vertebrae, with\n placement of a fibular bone graft. There is no interval change in alignment.\n There is an expected degree of postoperative prevertebral soft tissue\n swelling. There is no bony encroachment of the spinal canal. A small amount\n of fluid is incidentally noted within the mastoid air cells bilaterally.\n\n IMPRESSION: Post surgical changes from C3 through C7 as described above, with\n fixation screws in the C3 and C7 vertebral bodies.\n\n" }, { "category": "Radiology", "chartdate": "2189-11-15 00:00:00.000", "description": "O C-SPINE (PORTABLE) IN O.R.", "row_id": 746227, "text": " 11:33 AM\n C-SPINE (PORTABLE) IN O.R. Clip # \n Reason: SCREW REMOVAL FROMCERVICAL SPINE HARDWARE, ALSO, CHECK C- SPINE ALIGNMENT.\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION: Screw removal from cervical spine hardware.\n\n PORTABLE C-SPINE IN O.R.: AP and lateral views were obtained. There is a\n plate with screws traversing C3 and C7 vertebral bodies. One of the right\n upper screws has been removed since comparison films. There is fusion\n of C3 through C7 vertebral bodies.\n\n" }, { "category": "Radiology", "chartdate": "2189-11-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 746259, "text": " 12:15 PM\n CHEST (PA & LAT) Clip # \n Reason: FOLLOW UP PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n FOLLOW UP PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old woman follow-up pneumonia.\n\n CHEST, TWO VIEWS: Comparison is made to a prior study of . The heart\n is normal in size. Again noted is prominence of the right hilum. There is\n consolidation in the left lower lobe with a pleural effusion. A small\n effusion is also noted on the right.\n\n IMPRESSION:\n\n 1) Left lower lobe pneumonia unchanged in appearance.\n\n 2) Prominent right hilar contour. A CT is recommended for further\n evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2189-11-19 00:00:00.000", "description": "CHEST FLUORO", "row_id": 746474, "text": " 1:56 PM\n CHEST FLUORO Clip # \n Reason: need status of left diaphragm.need sniff test.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n need status of left diaphragm.need sniff test.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post cervical surgery with possible paralysis of the\n hemidiaphragm. Assess under fluoroscopic guidance.\n\n TECHNIQUE: Under fluoroscopic guidance, inspiration and expiration views were\n obtained.\n\n FINDINGS: Normal mobility of both hemidiaphragms. No paradoxical movement.\n Note is made of a left basilar opacity which may represent atelectasis and/or\n infiltrate.\n\n IMPRESSION: Normal movement of the left hemidiaphragm.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-11-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 746560, "text": " 3:20 PM\n CHEST (PA & LAT) Clip # \n Reason: left lower lobe consolidation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n left lower lobe consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Left lower lobe consolidation.\n\n Compared to \n\n The heart size is normal. The aorta is slightly unfolded. There remains the\n prominence of a right hilar contour. Pulmonary vascularity is not engorged.\n\n There is persistent elevation of a left hemidiaphragm. There is improving\n adjacent lung opacity suggesting atelectasis. There may be minimal blunting\n of the left costophrenic sulcus posteriorly. The right costophrenic angle is\n sharp and the right lung remains without evidence of consolidation.\n Postoperative changes were observed in the neck. There is some minimal\n scarring at the apices.\n\n IMPRESSION:\n\n 1. Improving left lower lobe opacity with minimal residual opacity suggestive\n of atelectasis. There remains elevation of the left hemidiaphragm. It is\n difficult to exclude a very small pleural effusion posteriorly.\n\n 2. Persistent fullness of the right hilum; although possibly vascular, right\n hilar mass cannot be excluded and contrast enhanced CT may be helpful for more\n complete assessment.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-11-20 00:00:00.000", "description": "L CHEST (LAT DECUB ONLY) LEFT", "row_id": 746559, "text": " 3:20 PM\n CHEST (LAT DECUB ONLY) LEFT Clip # \n Reason: left lower lobe consolidation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n left lower lobe consolidation\n ______________________________________________________________________________\n FINAL REPORT\n LATERAL DECUBITUS CHEST:\n\n Compared to previous PA and lateral chest radiograph from earlier the same\n day.\n\n A left lateral decubitus chest radiograph is somewhat limited due to dense\n overlying breast tissue and suboptimal positioning. No definite layering left\n pleural effusion is identified. There is apparent elevation of left\n hemidiaphragm as demonstrated on recent chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2189-11-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 746037, "text": " 8:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESSMENT OF ENDOTRACHEAL TUBE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman S/P C4-C6 CORPECTOMY AND C3-7 ANTERIOR FUSION AND REMAINS\n INTUBATED POST-OP\n REASON FOR THIS EXAMINATION:\n ASSESSMENT OF ENDOTRACHEAL TUBE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 59 year old woman status post C4-C6 corpectomy and anterior\n effusion of C3 through 7. Postop assessment for endotracheal tube placement.\n\n CHEST - PORTABLE: Comparison is made to a prior study of . The heart\n is normal in size. The mediastinal contours are unremarkable. There is\n prominence of the right hilar contour which is unchanged in comparison to the\n prior study. The pulmonary vasculature is normal. There is some atelectasis\n at the left lung base. There are no pleural effusions.\n\n IMPRESSION:\n\n 1. Satisfactory position of the ET tube. The tip is located 5.4 cm from the\n carina.\n 2. Atelectasis at the left lung base.\n 3. Prominence of the right hilar contour. This is very smoothly marginated.\n Differential diagnosis includes a bronchial cyst or lymphadenopathy. A CT\n examination is recommended for further evaluation.\n\n" }, { "category": "Nursing/other", "chartdate": "2189-11-12 00:00:00.000", "description": "Report", "row_id": 1479002, "text": "SICU UPDATE NOTE\nNEURO: PT SEDATED ON PROPOFOL INFUSION, WAKES TO NAME, OPENS EYES, FC'S AND MAE, PERLA, COUGH, GAG PRESENT. PLAN IS TO D/C'D PROPOFOL AND WEAN TO EXTUBATE. ICP IN PLACE, ICP RUNNIN , DRAIN AT 15CM ABOVE TRAGUS, DRAINING MODERATE AMOUNT OF BLOOD TINGED DRAINAGE. PT A HEAD CT, NO CHANGES FROM PRIOR CT\n\nCV: TELE NSR 60'S, GOAL IS TO MAITAIN SBP <150, NEED TO START NIPRIDE ONCE PROPOFOL IS TURNED OFF, DISTAL PULSES PALPABLE, SKIN, WARM AND DRY.\n\nRESP: PLAN IS TO PLACE PT ON CPAP, TO WEAN TO EXTUBATE. LS CTA, SUCTIONED FOR THICK, WHITE SECRETIONS, 02SATS 99%.\n\nGI: NPO AT THIS, ABD SOFT, NT, ND BS'S PRESENT, OGT-CLWS DRAINING SMALL AMOUNT OF BILIOUS.\n\nGU: FOLEY PATENT FOR CLEAR, YELLOW URINE, UO QS.\n\nID: AFEBRILE, ON KEFZOL FOR ICP DRAIN.\n\nSKIN: INTACT\n\nA. STABLE\nP. WEAN TO EXTUBATE, FOLLOW NEURO EXAM.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-11 00:00:00.000", "description": "Report", "row_id": 1478999, "text": "CTIC/SICU NSG ADMISSION NOTE\n\nMrs. is a 59yo female admitted to CTIC/SICU post-op for airway protection/intubation overnoc secondary to long OR time. Surgery done today--C4->C6 decortation and C3->C7 fusion. PMH significant for cervical spondolosis and spine stenosis. Pt has had numbness in both hands/fingers x1year--initially worked up as carpal tunnel syndrome then diagnosed with spondolosis/stenosis. In OR rec'd 6l crystalloids. EBL 1200, U/O 450. Allerg to CT contrast dye and codeine. Also has hx of motion sickness (wears scopolomine patch behind ear), cervical cystectomy and D+C. Non-smoker, social ETOH only.\n\nCURRENT STATUS:\nNeuro: Sedated with Propofol at 50mcg/kg/min at present. Arouses to voice, MAE to command. PERL, 3mm, brisk. Hand grasps equal, strong. Does move toes to command weakly. Will add Morphine when available from pharmacy and titrate down Propofol as tolerated. Aspen collar in place.\n\nCV/Pulm: VSS. MP=NSR. Hx LBBB. Maintained on vent AC12x600x60% with 5peep. Suct for scant thin white sec via ETT. BS coarse bil. ABG sent, results pending.\n\nGI/GU: Abd soft, BS absent. Sub I and resident to place OGT as pt has hx of n/v with motion sickness. U/O borderline qs via foley.\n\nID: Tmax=100.1 PO. Pt rec'd Ancef in OR at 1630; to have Ancef x24hrs post op--next dose due at 2400.\n\nInteg: Intact. Arms, legs edematous. IV access poor--currently has periph IV R hand and R foot. No open areas noted.\n\nPsychosocial: Emotional support given to pt and husband.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-11 00:00:00.000", "description": "Report", "row_id": 1479000, "text": "CTIC/SICU ADDENDUM\nOGT placed by resident--able to auscultate air over abdomen however no drainage. Placed to LCS. U/O increased once IV changed to LR at 100ml/hr. Morphine at 5mg/hr started at 2200. Propofol decreased to 30mcg/kg/min briefly but pt more awake, coughing so gtt increased back to 50mcg/kg/min. Remainder assess unchanged/per carevue.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-12 00:00:00.000", "description": "Report", "row_id": 1479003, "text": "SICU TRANSFER NOTE 7A-3P\nREVIEW OF SYSTEMS\n\nNEURO: PROPOFOL AND MORPHINE GTT D/C PRIOR TO EXTUBATION. PT A0X3 ALTHOUGH CLOUDY AT TIMES REGARDING TIME OF DAY. SLIGHTLY ANXIOUS AT TIME. ASPEN COLLAR INTACT WITH ORIGINAL SURGICAL DSG D&I. PT WITH EQUAL HAND GRASPS BILAT AND EQUAL STRENGTH IN LOWER EXTREMETIES. WHEN GETTING PT OOB LEFT ARM WAS NOTED TO BE SIGNIFICANTLY WEAKER. PT ABLE TO ONLY LIFT ARM MINIMALLY FROM SHOULDER AND LIFTS WEAKLY FROM ELBOW. COORDINATION IN LEFT ARM APPEARS TO BE OFF AS WELL. ORTHO AND SICU TEAMS AWARE. OOBX2 MIN. ASSIST FOR 1/2HR AND DIDN'T TOL WELL D/T DIZZINESS AND ANXIETY R/T INABILITY TO MOVE ARM.\n\nCV: HEMODYNAMICALLY STABLE. HR 110'S ST WITH REST AND INCREASING TO 130'S WHEN GETTING OOB. OCC PVC NOTED. SBP 120-150. +PP IN LOWER EXTREMETIES WITH RLE SLIGHTLY COOLER THEN LEFT. PIV IN R HAND.\n\nRESP: L/S CLEAR AND DIMINISHED AT BASES. EXTUBATED THIS AM AT 10A. TOL WELL. O2SATS 96-97% ON 50% FACEMASK AND 5LNC. OCC STRONG DRY COUGH NOTED. NO SOB OR RESP DISTRESS NOTED.\n\nGI: ABD SOFTLY DISTENDED WITH HYPOACTIVE BS. REMAINS NPO D/T NAUSEA. MEDICATED WITH ZOFRAN AND REGLAN FOR NAUSEA THIS AM WITH EFFECT. C/O MOD AMT OF DIZZINESS AND NAUSEA WITH MOVEMENT THAT SUBSIDES ON ITS OWN. NO STOOL OR FLATUS NOTED.\n\nGU: U/O ADEQUATE. IVF CONT LR AT 100CC/HR.\n\nHEME: HCT STABLE\n\nENDO: NO ISSUES\n\nID: AFEBRILE. LAST DOSE OF KEFZOL DUE AT 4PM.\n\nSKIN: DSG INTACT TO NECK. NO SKIN BREAKDOWN NOTED.\n\nSOCIAL: HUSBAND X2 AND WILL BE INTO SEE PT .\n\nA: STABLE S/P FUSION.\nP: CONT TO MONITOR PROGRESS OF L ARM, INCREASE ACTIVITY AS TOL, ADVANCE DIET AS TOL, RX NAUSEA AND DIZZINESS AS NEEDED, AND SUPPORT PT AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2189-11-12 00:00:00.000", "description": "Report", "row_id": 1479001, "text": "R/SICU Nursing Progress Note\nS:\nO: Neuro: sedated with propofol and morphine for pain. Pt. arouses to voice easily, moves all extremities, denies pain. Has sensation in all extremities. Aspen collar in place. PERRLA\nCVS: stable, receiving fluids @ 100cc/hr\nRESP: remains vented, minimal secretions, will wean and extubate most probably later this am\nGU: urine output adequate with increase earlier of IV fluid rate. Lytes repleted\nGI: og tube in place with minimal drainage, no GI prophylaxis\nENDO: no issues\nSKIN: intact, neck dsg dry and intact, minimal hemovac output.\nACTIVITY: assists with turning\nHEME: hct 29, coags ok, on pneumoboots\nSOCIAL: calm. husband called 2 times and updated on condition, all questions answered.\nA: stable, s/p cervical fusion\nP: wean and extubate, ??need for GI prophylaxis, PCA for pain control, OOB to chair today. ??transfer from ICU after extubation.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2167-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 798500, "text": " 6:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u ? infilatrate on previous CXR\n Admitting Diagnosis: R/O PANCREATITIS-SPONTANEOUS BACTERIAL PERITONITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with cirrhosis, a/w fever\n REASON FOR THIS EXAMINATION:\n f/u ? infilatrate on previous CXR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, question of pneumonia suggested on prior films.\n\n FINDINGS: AP upright view is compared to PA and lateral views dated . The previously noted round opacity at the left lung base is not\n identified on the current study. The lungs appear clear. There is no pleural\n effusion. The heart, mediastinum and pulmonary vessels are within normal\n limits. The visualized osseous structures are unremarkable.\n\n IMPRESSION: No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-08-28 00:00:00.000", "description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT", "row_id": 798542, "text": " 1:09 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: ABDOMINAL PAIN AND QUESTION SOURCE OF FEVER, UNABLE TO TOLERATE CT\n Admitting Diagnosis: R/O PANCREATITIS-SPONTANEOUS BACTERIAL PERITONITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with hep C cirrhosis, p/w new fever, worsened abdominal pain,\n back pain.\n REASON FOR THIS EXAMINATION:\n r/o abdominal source of fever\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rule out abdominal source of fever.\n\n COMPLETE ABDOMINAL ULTRASOUND: The gallbladder is distended and contains\n multiple stones. There is no gallbladder wall thickening. The liver is\n hyperechoic and heterogeneous in texture which is consistent with underlying\n liver disease. There is no focal lesions in the liver. There is a moderate\n amount of ascites. The common bile duct measures 0.3 cm and is not dilated.\n There is no intrahepatic bile duct dilatation. Both kidneys look unremarkable\n without evidence of hydronephrosis, stones, or masses. The pancreas is not\n well visualized.\n\n The study was limited due to patient body habitus and the presence of gas.\n\n IMPRESSION:\n 1) Cholelithiasis but no evidence of acute cholecystitis.\n 2) Liver is coarse and heterogeneous which is consistent with underlying\n liver disease.\n 3) Moderate amount of ascites.\n 4) The study was limited due to the patient's body habitus and the presence\n of gas.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2167-08-29 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 798627, "text": " 1:18 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ABD AND BACK PAIN, UTI\n Admitting Diagnosis: R/O PANCREATITIS-SPONTANEOUS BACTERIAL PERITONITIS\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with HCV, ETOH cirrhosis p/w abd, back pain and UA suggestive\n of UTI\n REASON FOR THIS EXAMINATION:\n r/o pyelo, r/o pancreatitis (okay to use po contrast)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CLINICAL INDICATION: 46 year old male with hepatitis C and cirrhosis, now\n with abdominal and back pain.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases through\n the pubic symphysis without intravenous contrast due to patient's elevated\n creatinine.\n\n Comparison: \n\n CT OF THE ABDOMEN WITH IV CONTRAST: The visualized lung bases demonstrate\n minor dependent bibasilar atelectatic changes. There are no pleural or\n pericardial effusions. The liver is shrunken in size and nodular in contour,\n compatible with the patient's known history of cirrhosis. There is a moderate\n amount of ascites present, not significantly changed in the interval. Note is\n again made of fluid within the gallbladder fossa. The gallbladder appears\n distended without associated pericholecystic fluid or wall edema. A 1.1cm\n gallstone is again noted. Allowing for the limitations of a non-contrast\n examination, the pancreas, spleen, kidneys, and adrenal glands are within\n normal limits. The stomach and opacified loops of small and large bowel are\n unremarkable. No significant retroperitoneal or mesenteric lymph adenopathy is\n identified.\n\n CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder and distal ureters are\n normal. There are prostatic calcifications. There is mild thickening of the\n sigmoid colon without adjacent stranding, a finding which may be secondary to\n the patient's cirrhosis and hypoproteinemia. However, focal colitis cannot be\n excluded. A small amount of free fluid is identified.\n\n Bone windows: No significant osseous abnormalities are detected.\n\n IMPRESSION:\n 1. Distention of the gallbladder without associated wall edema or\n pericholecystic fluid. An ultrasound of the right upper quadrant is\n recommended for further evaluation if clinically warranted.\n 2. Mild thickening of the sigmoid colon without adjacent stranding. Although\n this finding may be secondary to the patient's cirrhosis, focal colitis cannot\n be excluded.\n\n (Over)\n\n 1:18 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ABD AND BACK PAIN, UTI\n Admitting Diagnosis: R/O PANCREATITIS-SPONTANEOUS BACTERIAL PERITONITIS\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2167-08-27 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 798479, "text": " 6:42 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with cirrhosis p/w new fever, abd pain.\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 46 year old male with fever and abdominal pain.\n\n TECHNIQUE: PA and lateral chest.\n\n COMPARISON: .\n\n FINDINGS: The cardiac and mediastinal contours are within normal limits. The\n pulmonary vasculature is not engorged. There is a vague, rounded, opacity\n within the left lower lobe which may represent asymmetric breast tissue in a\n cirrhotic patient. However, an early focus of pneumonia cannot be definitively\n excluded. The lungs are otherwise clear. There are no pleural effusions. The\n visualized osseous structures and soft tissues are unremarkable.\n\n IMPRESSION: Vague, ill-defined rounded opacity overlying the left lower lobe,\n seen only on the frontal view. Although this likely represents superimposed\n density from asymmetric gynecomastia, an early focus of pneumonia cannot be\n definitively excluded. Short-term follow-up CXR is recommended.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2167-08-29 00:00:00.000", "description": "Report", "row_id": 1367765, "text": "Nursing Progress Note.\n\nHEME: Pt cont to have a stable hematology (last drawn @ 16:00) labs c a HCT value of 36.9., a plt co of 50 and a WBCC of 5.5. INR is also stable c a value of 1.8. No overt bleeding evident c nl VS, guaic negative stool and a lack of new abd c/o. Will cont to monitor hematology labs Q 12 hours as desired by team.\n\nGI: Pt weaned onto full PO diet c fair intake noted for dinner. Pt taking good PO fluid intake and therefore IV hydration is on hold. Pt was able to tol two bottles of Bari-cat and underwent his CT c contrast s diff, 600mg of IV Acetylsisteine admin post procedure as ordered. CT results are currently pending. Pt has passed over one liter of soft stool in the past three hours s/p PO contrast intact and AM Lactulose, stool is presently guaic negative. Icteric sclera, + jaundice.\n\nCV: Afebrile. NSR, no ectopy. HDS. OOB to chair, ambulating in unit c fair tol and only requiring supervision. Pt denies feelings of dizzyness and/or lightheadedness while OOB/ambulating. +2 LE edema noted. Improved UO today, voiding dark amber urine into urinal.\n\nMS: times three, conversant//cooperative in NAD. No obvious confusion.\n\nSOC: Wife visited this afternoon and kept up to date c POC/pt status. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Pt is on liver transplant list. Pt awaiting bed on general medical floor and is \"called out\".\n" }, { "category": "Nursing/other", "chartdate": "2167-08-29 00:00:00.000", "description": "Report", "row_id": 1367766, "text": "Nursing Transfer Note.\n\nBriefly, this is a pleasant/conversant 46 yr old man that was admitted to /EW on the evening of c a recent history of chills/fever, nausea/vomiting, abd/back pain, c c/o lightheadedness c standing. In EW the pt was given oral contrast and proceeded to vomit BRB. An emergent EGD (+varices c banding in place, +gastropathy, sm blood oozing from fundus -- o/w nl EGD findings) was performed and the pt was transferred to MICU-A for close monitoring. PMH includes; ETOH/Hepatitis C cirrhosis stage IV, stage III Varices s/p banding, CRF, hepatic encephalitis, HTN. The pt is on the liver transplant list presently. Pt recently admitted for a short term stay to from - for encephalitis assoc c non-compliance c PO Lactulose. During this admit the pts HCT drifted down from 31.8 to 26.6 and he is s/p 3 units of PRBC's. In addition, the pt has received four units of FFP for elevated INR. The pt received an abd US which was negative and had a CT c oral/IV contrast today, results of which are currently pending. The pt has been started on a regular low Na/K renal diet c good tol. HCT, INR, and Plt counts are all stable and the pt has not had any episodes of bleeding (guaic negative stools). Currently we are checking his HCT Q 12 hours. Pt was OOB and ambulating on unit c good tol. Pt spirits are good, his supportive wife visits daily and is up-to-date on POC/pt status. The pt currently has two large bore PIV's in his LUE (14# and 18# gauges). The pt is HDS, afebrile, NSR c no ectopy noted and is in NAD. The pt is conversant, follows commands, and cooperative. UO is adequate. The pt was informed of his transferable status. The pt is a Full Code. Universal isolation procedures are in place. Please see today's Nursing Progress Note for more comprehensive details on how the pt did today. Pt reports chronic lower back/abd pain, occ given PO Acetaminophen c + results reported by pt. Please call MICU-A @ c any questions please.\n" }, { "category": "Nursing/other", "chartdate": "2167-08-29 00:00:00.000", "description": "Report", "row_id": 1367767, "text": "D pt alert and oriented MAE oob to comode.\nCV: NSR no VEA noted. Palp DP/PT. VSS see care view. sandostaton @ 50mcg/hr started midnigt last HCT 36.9 and PT/PTT INR 1.8 @ 1500 . 2 L PIV patent.\nLungs clear throughout/\nGI: ABD distended Ascites. Bowel sounds present no N/V. frequent stool from barium soft formed colored.\nGU: voiding well clear yellow urine.\nSkin: intact\nA stable ready for transfer to floor\nR transfer to 6 report called to floor.\n" }, { "category": "Nursing/other", "chartdate": "2167-08-28 00:00:00.000", "description": "Report", "row_id": 1367763, "text": "Nursing Progress Note.\n\nCV: Pt is HDS, NSR, no ectopy and low grade temp to 100.6 orally (med c 650mg Acetaminophen @ 16:00). Pt SBP in the 88-110 range today, pt not tachycardic. OOB to chair c supervision and good tol reported by pt for two hours this afternoon. EKG obtained this AM c K value = 6.1, no changes reported by team. Pt subsequently med c 30ml Kayexalate PR enema, 12:00 K value therapeutically dropped to 5.0. Pt med c 10mg SQ Vit K per team order. Two large bore PIV's are in place in RUE. Normoglycemic.\n\nHEME: Cont to follow Q 6 hr HCT's, 12:00 HCT value = 30.1 s/p 2 units of PRBC Tx's, will check next HCT @ 18:00 (no evidence of acute bleeding @ this time)(HCT goal =/> 30). 12:00 Plt co value = 50, team aware, will cont to follow trend. 12:00 INR value = 1.9, pt currently receiving 2nd unit of single donor plasma, will cont to follow coag time trend as requested by team.\n\nGI: Pt c no stool output or c/o nausea/vomiting thus far today. Pt reports mild dull abd discomfort which he has rated between 1 and 2 today. Brown formed stool output this AM following enema admin, no melena/bloody stool output evident. Pt reports poor appetite, now taking ice chips sparingly -- pt is currently NPO x meds. Pt started on TID Lactulose. IV Octreotide gtt cont as ordered. BS abd US performed today, results pending. Abd CT on hold until results of US are known/discussed by team.\n\nGU: Pt able to void 250ml of dark amber urine, spot UA and urinalysis sent for analysis. Pt refused placement of a foley cath, team notified of pt refusal.\n\nRESP: Pt respirating comfortably on RA c nl sats/RR. LSCTA.\n\nMS: Pt is times three, conversant/pleasant. Follows commands. OOB to chair c minimal assistance c good tol noted. Pt reports HA.\n\nSOC: Wife @ BS for many hours today, kept up-to-date c POC/pt status. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments.\n" }, { "category": "Nursing/other", "chartdate": "2167-08-29 00:00:00.000", "description": "Report", "row_id": 1367764, "text": "NURSING NOTE\nPT REMAINS IN MICU FOR MONITORING OF HCT LEVELS, AND HEMODYNAMIC MONITORING.\nNEURO: ALERT W/A, MAE'S, GENL WEAKNESS R/T DIS PROCESS. PERL, SCLERA ICTERIC, IS AND COOP.\n\nRESP: ON RA, SATS 97-98%, BBS CTA, FEW FINE CRACKLES AT BASES, NPC. EVEN AND UNLAB RR MID TEENS TO 20'S. DENIES SOB.\n\nCV: HR SR, NO ECT. PALP PULSES. PIV LEFT HAND W/ OCTREOTIDE AT 50MCG/HR, AND LFT AC 14 G USED FOR TRANSFUSION OF 1PC, AND IVF'S. NS INFUSING AT 75/HR, HCT CHECKED PRIOR TO PC, AND WAS 29, FROM 26. SEE AM LABS FOR LATEST HCT/LABS. DENIES CP. COLOR PINK, AFEBRILE.\n\nGI/GU: VOIDED SL CLOUDY DK AMBER URINE. REFUSED FOLEY. HAD LG SOFT BROWN STOOL, HEME POS. PT WAS TO GO FOR ABD CT LAST EVE, DRANK 2 BTLS OF BARICAT LIQ, AND WHEN ARRIVED IN CT, AN ORDER TO CANCEL WAS GIVEN. PT IS TO HAVE IT DONE W/ MORE CONTRAST PO, AS WELL AS IV. LIVER TEAM REQUESTED ACETYLCYSTEINE 600 MG BE GIVEN IN AM, AND AFTER CT DONE TO HELP \"PROTECT KIDNEY FUNCTION\". ABD SEMISOFT, ACITES. C/O MILD DISCOMFORT IN ABD IN EVE, HAD CRAMPING AND SOME DISCOMFORT AFTER PO CONTRAST. NO VOMITING. TOL FULL LIQ DIET. HAD LAST EVE.\n\nAFEBRILE. CONT ON IV FLAGYL FOR ENCEPHALOPATHY, AND LEVOFLOXACIN.\nPLEASANT AND COOP\n" }, { "category": "Nursing/other", "chartdate": "2167-08-28 00:00:00.000", "description": "Report", "row_id": 1367762, "text": "NURSING NOTE\nPT ADM TO MICU S/P 5 BLOODY STOOLS IN EW, VOMITED CT CONTRAST, W/ BRB. CAME FOR EMERGENT ENDOSCOPY.\nNEURO: AAO X 3. MAE'S, IS WEAK, AND TIRED. HAD SHIVERS W/ TEMP 100.7 UPONN ADM. HAS BEEN ON LEVOFLOXACIN SINCE FOR ENCEPHALOPATHY HE STATES. COMES IN NOW W/ FEW DAY HX OF FEVERS. PLEASANT AND COOP. RECVD VERSED 2 MG, AND DEMEROL 75 FOR PROCEDURE. TOL WELL, AND HAS BEEN ASLEEP MOST OF NIGHT.\n\nRESP; OP2 SATS 98% RA UPON , PLACED ON 4L NC FOR ENDOSCOPY AND KEPT AS HE WAS SEDATED, AND SBP IN 80'S. SATS HAVE STAYED 98-100%. BBS CTA, NPC. EVEN AND UNLABORED.\n\nCV: HR ST 120'S INITIALLY, FL BOLUSES GIVEN, AND IVF'S REMAIN AT 125/HR (NS). HCT AT 9PM WAS31.8 IN EW, 3 AM=28, AND 4AM=26.2. COLOR PINK, W/D/I. RECEIVED FIRST OF TWO PC'S, AND 2 U FFP. PT TEMP SLIGHTLY AFTER BEGINING OF FIRST, BUT NO HIGHER THAN 100.7. IV ACCESS GOOD. 14 G TO LFT AC, 18 TO RT HAND. REPEAT HCT SENT AFTER FIRST PC. THEN PLEASE GIVE SECOND. SBP REMAINS 86-98/40-50. HR NOW SR 90'S.\n\nGI/GU: FINALLY USED URINAL, CRANBERRY/BROWN URINE, 200CC. AMNT WAS DUMPED , BUT A CULTURE NEEDS TO BE DONE W/ NEXT VOID. NO STOOL, BELCHING NOTED. NPO, TAKING FEW ICE CHIPS ONLY. STATES HE \"FEELS BETTER TODAY\" DENIES N/V.\n\nPT ADM W/ CHILLS AND FEVERS, REMAINS ON LEVOFLOXACIN, METRONIDIAZOLE. IS ORDERED FOR CT OF ABD TODAY. QUESTION OF GALLSTONES, VS PANCREATITIS, PT'S LFTS ARE VERY ELEVATED. IS ON IV OCTREOTIDE 50 MCG/HR.\n" }, { "category": "ECG", "chartdate": "2167-08-28 00:00:00.000", "description": "Report", "row_id": 174266, "text": "Sinus rhythm. No diagnostic abnormality.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2178-12-16 00:00:00.000", "description": "Report", "row_id": 1307408, "text": "FOCUS: CONDITION UPDATE\nSEE CAREVUE FOR SPECIFIC VITAL SIGNS/LAB/ASSESSMENTS.\nD: PATIENT ADMITTED TO SICU FROM ED, E/P INTRAMARENCHYMAL BLEED NEAR WEHRE PREVIOUS BRAIN TUMOR WAS REMOVED.PREVIOUS HISTORY SIGNIFICANT FOR RIGHT PARIENTAL BRAIN TUMOR RESECTION , WITH RECURRENCE COMPLICATED WITH CSF LEAK. MENINGITIS, COLOSTOMY DUE TO DIVERTICULITIS WITH RECONNECTION , DEVELOPED DVT AFTER THIS--ON LOVONOX AT HOME.\nINTUBATED UPON ARRIVAL, IMMEDATELY EXTUBATED AS PATIENT WAS ALERT, FOLLOWING COMMANDS, TAKING GOOD TIDAL VOLUMES ON CPAP 5/5.\nDID WELL FOLLOWING EXTUBATION. WIFE AT , VERY SUPPORTIVE.\nSLEEPY BUT EASILY AROUSABLE, CONSISTANTLY FOLLOWING COMMANDS WITH GOD STREGNTH IN EXTRMITIES, ORIENTED TIMES , WITH SPEECH SLURRED AT FIRST, BUT IMPROVING AS NIGHT GOES ON (WAS A FAIRLY TRAUMATIC INTUBATION OSH ACCORDING TO WIFE).\nNEURO ASSESSMENT PER FLOW SHEET.\nP:CURRENTLY ON NEURO MED SERVICE ALTHOUGH KNOWN TO NEURO . ?PLAN FOR TREATMENT OF BLEED. PATIENT IS CURRENTLY ON CHEMO TREATMENT FOR BRAIN TUMOR.\nWILL CALL HO WOTH ANY CHANGES.\n" }, { "category": "Nursing/other", "chartdate": "2178-12-16 00:00:00.000", "description": "Report", "row_id": 1307407, "text": "Resp Care\nPt. received via ED following witness grand mal szs. Intubated by EMS for AP. Discovered to be in esophagus upon arrival at OSH. Re-intubated for AP. Brought for CT of both head, then chest w/o incident.\nThis morning transferred to unit following commands with spontaneous respirations. RSBI 25. Decision made to extubate since pt. had become agitated, attempting to remove ett. himself Placed on 4lnc, which he is tolerating well with a SPO2 100%, RR 15. No ARD or stridor noted at this time.\n" }, { "category": "Radiology", "chartdate": "2178-12-18 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 888813, "text": " 7:55 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: eval bleed, extent of tumor\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with oligodendroma and head bleed seen on CT\n REASON FOR THIS EXAMINATION:\n eval bleed, extent of tumor\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with oligodendroglioma and hemorrhage, for\n further evaluation.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2 susceptibility and diffusion\n axial images of the brain were obtained before gadolinium. T1 axial, sagittal\n and coronal images of the brain were obtained following the administration of\n gadolinium. Comparison was made with the previous MRI examination of \n and correlation was made with the head CT of .\n\n FINDINGS: Again postoperative changes are noted in the right temporoparietal\n region. There is a small area of acute/subacute hemorrhage seen in the right\n periatrial region as seen on the CT of . Following gadolinium\n enhancement along the surgical cavity, the right occipital and right\n periatrial region is noted. There is also enhancement seen surrounding the\n area of hemorrhage which is new since the previous MRI examination. Overall\n the white matter edema has not significantly changed compared to the previous\n study, however. There is no midline shift seen. Moderate prominence of\n ventricles is noted including prominence of the right temporal .\n\n IMPRESSION: Status post craniotomy on the right temporoparietal region with\n enhancement around the surgical cavity. A small new area of hemorrhage and\n new surrounding enhancement in the right periatrial region since the MRI of\n . No evidence of midline shift seen. No other areas of abnormal\n enhancement are noted.\n\n" }, { "category": "ECG", "chartdate": "2178-12-17 00:00:00.000", "description": "Report", "row_id": 188835, "text": "Sinus rhythm. Ventricular premature beats, unifocal and fixed-coupled. Right\nbundle-branch block. Compared to the previous tracing of no significant\nchange.\n\n" }, { "category": "ECG", "chartdate": "2178-12-15 00:00:00.000", "description": "Report", "row_id": 188836, "text": "Normal sinus rhythm, rate 68. Right bundle-branch block. Occasional ventricular\npremature beat. Compared to the previous tracing of ventricular ectopy\nis new.\n\n" }, { "category": "Radiology", "chartdate": "2178-12-16 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 888478, "text": " 12:45 AM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: Eval for interval changes in DVTs\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with h/o PE and bilat DVT on lovenox, now with\n intracranial hemorrhage and CTA with resoltion of PEs\n REASON FOR THIS EXAMINATION:\n Eval for interval changes in DVTs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of PE and bilateral DVT, on Lovenox.\n\n BILATERAL LOWER EXTREMITY VEINS: The left common femoral, superficial\n femoral, popliteal, and right common femoral, greater saphenous, superficial\n femoral, and popliteal veins all demonstrate patency with normal color flow\n and Doppler waveform as well as normal compressibility, augmentation, and\n respiratory variation. No intraluminal thrombus is identified.\n\n IMPRESSION: Interval resolution of bilateral deep vein thromboses. No\n intraluminal thrombus is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-12-15 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 888473, "text": " 10:36 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: assess for interval change in PEs\n Field of view: 38 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58M h/o oligodendroma new head bleed, known PEs\n REASON FOR THIS EXAMINATION:\n assess for interval change in PEs\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MJGe WED 8:40 AM\n interval resolution of bilateral PEs. lungs show bibasilar atelectasis but no\n focal airspace consolidation.\n WET READ VERSION #1 MJGe TUE 11:44 PM\n interval resolution of bilateral PEs. lungs show bibasilar atelectasis but\n no focal airspace consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old man with oligodendroglioma with known pulmonary\n emboli.\n\n COMPARISON: CT angiogram .\n\n TECHNIQUE: Multidetector CT images were obtained from the lung apices to the\n mid abdomen first without contrast with a low-dose technique, followed by CT\n angiogram of the chest. Coronal and sagittal and oblique sagittal reformatted\n images were obtained.\n\n CT ANGIOGRAM OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There has\n been interval resolution of the filling defects within the pulmonary artery\n supplying the left lower, right upper, right middle, and right lower lobes.\n The heart, pericardium, and great vessels are unremarkable. The airways are\n patent to the segmental level bilaterally. There is no pathologically\n enlarged axillary, hilar, or mediastinal lymphadenopathy. The lung fields\n show dependent changes at the bilateral lung bases. There are tiny bilateral\n pleural effusions, right greater than left. The visualized intra-abdominal\n organs are unremarkable. An NG tube courses through the esophagus and into\n the stomach.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n Degenerative disc disease is seen within the thoracic spine.\n\n CT REFORMATS: Coronal, sagittal, and oblique sagittal reformatted images\n confirm the axial findings. Value grade 1.\n\n IMPRESSION: Interval resolution of bilateral pulmonary emboli.\n\n (Over)\n\n 10:36 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: assess for interval change in PEs\n Field of view: 38 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2178-12-15 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 888464, "text": " 7:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with h/o brain tumor w/ seizures, ? new rt ICH\n REASON FOR THIS EXAMINATION:\n assess for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MMBn WED 7:34 AM\n New 12 mm area on calcification/enhancement below prior tumor resection site\n in the right parieto-occipetal region. The rounded appearance suggest an\n underlying mass lesion.\n WET READ VERSION #1 MMBn TUE 9:07 PM\n New intraparenchymal hemorrhage below prior tumor resection site in the right\n parieto-occipetal region.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 58-year-old man with history of brain tumor (oligodendroglioma\n s/p resection) and seizures. Evaluate for new intracranial hemorrhage.\n\n COMPARISON: Noncontrast head CT dated and the MRI of . .\n\n TECHNIQUE: Routine noncontrast head CT.\n\n FINDINGS: An approximate 12-mm rounded area of increased density is seen\n within the right temporal lobe, below the area of tumor resection, where there\n is a known mass. This likely represents a focus of hemorrhage.\n\n There is stable hypodensity within the white matter within the temporal,\n parietal, and occipital lobes. Stable bilateral ventricular prominence is\n seen. No new areas of mass effect are identified. There are no findings to\n indicate acute territorial infarction.\n\n Surrounding soft tissue and osseous structures again reveal the right parietal\n craniotomy site.\n The sinuses are well aerated.\n\n IMPRESSION:\n Small focus of hemorrhage within the left temproal lobe tumor. No substantial\n change in the morphology of the brain or extent of edema.\n , Neurooncology was phoned with a change in the report at\n 9:37am on .\n\n" }, { "category": "Radiology", "chartdate": "2178-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888637, "text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58M with brain tumor s/p seizure yesterday, now extubated\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n HISTORY: Brain tumor and seizure.\n\n IMPRESSION: AP chest compared to .\n\n Lungs remain low in volume, but aside from linear atelectasis at the left\n base, essentially clear. There is no pleural effusion or evidence of central\n adenopathy. Heart is normal size and mediastinum is midline. Tip of the\n right subclavian infusion port projects over the SVC.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2151-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009992, "text": " 11:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with cholangitis.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cholangitis. Infiltrate.\n\n A single portable radiograph of the chest demonstrates a normal\n cardiomediastinal contour. The lung volumes are low, but the lungs are clear.\n There is blunting of the right costophrenic angle. No pneumothorax. A left\n thoracic cardiac pacer with dual leads is noted. The trachea is midline.\n\n IMPRESSION:\n\n Small right-sided pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-05-24 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 1010125, "text": " 9:36 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images done \n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pain fever and jaundice. Imaging showing CBD and\n gallstones\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n ERCP.\n\n COMPARISON: None.\n\n HISTORY: 74-year-old male with pain, fever and jaundice.\n\n FINDINGS: Eight ERCP images were obtained and submitted for review without a\n radiologist present. These demonstrate a filling defect within the common\n bile duct and cystic duct, concerning for stones. There is no biliary\n dilatation identified.\n\n IMPRESSION: Filling defect within the cystic duct and common bile duct\n concerning for stone. Biliary stent was placed within the common bile duct.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-05-23 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1009939, "text": " 5:55 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: EVAL FOR CHOLANGITIS, RUQ PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with onset epigastric pain, n/v, elevated t bili and alk phos\n at OSH, WBC elevated, concerning for cholangitis\n REASON FOR THIS EXAMINATION:\n eval for cholangitis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right upper quadrant abdominal ultrasound.\n\n INDICATION: Epigastric pain, nausea, vomiting, elevated liver enzymes.\n\n COMPARISONS: None.\n\n FINDINGS: There is no right upper quadrant ascites. The liver demonstrates\n an extremely coarsened echotexture. No definite focal mass lesion is\n identified; however, evaluation is limited given the diffusely increased\n echogenicity. There is no intra- or extra-hepatic biliary ductal dilatation\n with the common bile duct measuring 3 mm. The main portal vein is patent with\n normal hepatopetal flow. The gallbladder contains a solitary shadowing stone\n measuring 8 mm, which does not move with change in patient position, and may\n be impacted. The gallbladder is not distended and no wall thickening or\n pericholecystic fluid is present. There is a negative son sign.\n No hydronephrosis is present within the right kidney. The pancreas is not\n visualized given overlying bowel gas.\n\n IMPRESSION:\n 1. Diffusely and coarsely echogenic liver, likely secondary to fatty\n infiltration. However, other forms of diffuse liver disease including\n significant fibrosis/cirrhosis cannot be excluded.\n\n 2. Cholelithiasis, with possible calculus impacted in the gallbladder neck or\n the cystic duct, but no evidence of acute cholecystitis.\n\n 3. No specific evidence of choledocholithiasis, with normal caliber CBD.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-05-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010211, "text": " 4:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with cholangitis, now tachypneic.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Cholangitis, now tachypneic. Evaluate for infiltrates.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting upright position and analysis is performed in direct comparison with a\n preceding similar study of . A permanent pacer in left anterior\n axillary position connected to two intracavitary electrodes in unchanged\n position. No pneumothorax has developed. Heart size is unaltered. No\n pulmonary vascular congestion is present and no pulmonary infiltrate is\n identified. The previously described mild blunting of the right lateral\n pleural sinus has decreased and is barely detectable anymore.\n\n IMPRESSION: No evidence of CHF or acute pulmonary infiltrates. Regression of\n previously described minor pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-05-24 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1009958, "text": " 12:32 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Eval for cholangitis\n Admitting Diagnosis: CHOLANGITIS\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with epigastric pain, n/v, labs concerning for cholangitis, no\n biliary duct dilation on RUQ u/s\n REASON FOR THIS EXAMINATION:\n Eval for cholangitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd MON 1:06 AM\n Cholelithiasis. No specific evidence for cholangitis.\n\n Probable choledocholithiasis.\n WET READ VERSION #1 DSsd MON 1:03 AM\n Cholelithiasis. No specific evidence for cholangitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with epigastric pain, nausea and vomiting, labs\n concerning for cholangitis, but no biliary ductal dilatation on right upper\n quadrant ultrasound. Please evaluate for cholangitis.\n\n COMPARISON: Right upper quadrant ultrasound from previous day.\n\n TECHNIQUE: MDCT acquired axial imaging of the abdomen and pelvis was\n performed after administration of oral and intravenous contrast. Multiplanar\n reformatted images were obtained and reviewed.\n\n CT ABDOMEN: Visualized lung bases are normal. Liver contour is normal. No\n focal intrahepatic lesions are seen. There is no biliary ductal dilatation or\n ascites. There is diffusely decreased hepatic attenuation, most consistent\n with fatty infiltration of the liver. A few small calcified gallstones are\n seen within the gallbladder lumen, which is not distended, and there is no\n wall thickening or pericholecystic fluid. The common bile duct is not\n dilated, but there is probably at least one small stone within the distal CBD.\n Another stone is seen higher up, probably in the cystic duct, or possibly in\n the gallbladder neck. The pancreas and spleen are unremarkable. The adrenal\n glands are normal in size bilaterally. Kidneys enhance and excrete contrast\n symmetrically. There are bilateral simple renal cysts as well as smaller\n hypodensities bilaterally, which are too small to definitively characterize.\n Stomach and intra-abdominal loops of bowel appear normal. There is moderate\n atherosclerotic disease of the aorta with several focal areas of ulceration.\n There is no free air, free fluid, or abnormal intra- abdominal\n lymphadenopathy.\n\n CT PELVIS: There is somewhat featureless appearance of the distal sigmoid\n colon, which could suggest prior colitis. Otherwise, pelvic loops of large\n and small bowel are unremarkable. Foley catheter balloon is seen within\n decompressed bladder. There is no free pelvic fluid or abnormal pelvic or\n inguinal lymphadenopathy.\n (Over)\n\n 12:32 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Eval for cholangitis\n Admitting Diagnosis: CHOLANGITIS\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Post-surgical changes and clips are seen in the right inguinal region.\n\n OSSEOUS STRUCTURES: No suspicious lesions are seen. There is no fracture.\n There is mild degenerative change in the thoracolumbar spine.\n\n There is mild atherosclerotic calcification throughout the abdominal aorta and\n its branches, including calcification at the origins of the celiac artery and\n superior mesenteric artery, although no definite stenosis is seen.\n\n IMPRESSION:\n\n 1. Cholelithiasis, without evidence of cholecystitis. Probable\n choledocholithiasis, in the distal cystic duct or proximal common bile duct.\n No sign of common bile duct dilatation.\n\n 2. Bilateral simple renal cysts, and smaller incompletely characterized renal\n hypodensities.\n\n 3. Fatty liver.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-05-23 00:00:00.000", "description": "Report", "row_id": 1645312, "text": "admission note\nPt admitted from ED with abd pain, WBC 28, lactate 2.9, abd U/S at OSH showing cholangitis. Upon arrival to SICU pt alert and oriented, portuguese speaking. LS clear bilaterally, pox 94-98% on RA. Abdomen is large but soft, tender to palpate in RUQ area, positive BS. Pt had small BM X 1. Being prepped for abdominal CT with 2 bottles barocat. Pt being aggresively hydrated with NS at 200cc/hr and unasyn initiated. Pt afebrile on arrival as well.\nPLAN-pt to go abdominal US after adequate hydration and prep completed. Monitor vitals closely, PLAN for ERCP in am.\n" }, { "category": "Nursing/other", "chartdate": "2151-05-24 00:00:00.000", "description": "Report", "row_id": 1645313, "text": "NPN (NOC):\n\nPT IS MUCH IMPROVED OVERNOC. HIS TEMP IS FLAT AND HE DENIES PAIN. ABD CT DONE. PT IS NOW PASSING BARIUM. SBP'S ARE GOOD. UO IS EXCELLENT. D5W W/ 150 MEQ'S IS GOING AT 150 PER HR POST ABD D/T CONTRAST. UO IS EXCELLENT. HE HAS BEEN NPO. DTR WILL BE IN EARLY THIS AM TO TRANSLATE FOR HIM.\n\n" }, { "category": "Nursing/other", "chartdate": "2151-05-24 00:00:00.000", "description": "Report", "row_id": 1645314, "text": "Focused Nursing Note\nPlease see carevue flowsheet for further details\n\n74 y.o. male with admitted w/ cholangitis, s/p ERCP sphincterotomy, removal of impacted stone from CBD, stent placed CBD for moderate inflammation/edema. Pt tolerated procedure well.\n\nNeuro: Portugese-speaking, understands simple english, able to make needs met. A/O x 3, moves all extremities well, PERRL 3mm.\nDenies pain.\n\nResp: Tachypneic 28-34, denies SOB, lgs diminished t/o. Oxygenating well on 2L NC, productive cough pale yellow sputum. OOB to chair x 2 hrs.\n\nHemodynamics: Normotensive on maintenance fluids LR 100ml/hr. SBP range 104-114/50-70s. 100% V-paced HR 95-100, no ectopy. u.o. 50-200/hr, fluid balance +1200ml since admission to ICU. Hct stable 37.\n\nMetabolic/Nutrition: NPO continues. K+ 3.5, Mg 1.9, glucose 99-105.\nBilirubin/enzymes slight improved after ERCP.\n\nID: Tmax 101, Unasyn q6hr.\n\nPsychosocial: Pts daughter visits and calls for update often, understands plan of carem wishes to be updated frequently.\n\nPlan of Care: NPO, monitor hemodynamics, monitor fever curve, antibiotics as ordered. Pulmonary toileting as needed, encourage OOB to chair and ambulation. Education and encouragement re: plan of care ongoing to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2151-05-25 00:00:00.000", "description": "Report", "row_id": 1645315, "text": "Condition update\nSee careview for objective data/trends:\n\nAlert and oriented, primary language is Portugese although pt speaks some English and is able to follow commands and communicate needs without difficulty. Denies pain or discomfort. Continues to have low grade temps. Remains VPaced, no ectopy noted, has been 100%paced in regular rythmn overnight. BP stable. Lungs coarse with occasional insp wheezes, rr remains 30's although unlabored and pt denies sob. Dr aware, IVF rate decreased and ordered for neb tx prn. Sats 94% on 2 liters, increased to 3 liters and Sats 95-98% overnight. Abd soflty distneded, remains NPO. Foley with adequate urine output. Skin intact. Plan to cont to monitor hemodyanmics, resp status, probable transfer to floor if improvement in am labs.\n" }, { "category": "ECG", "chartdate": "2151-05-24 00:00:00.000", "description": "Report", "row_id": 214876, "text": "Atrio-ventricular sequential pacemaker with atrial sensing and ventricular\npacing with frequent atrial premature depolarizations. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2158-05-23 00:00:00.000", "description": "Report", "row_id": 179537, "text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing of ST-T wave changes are probably new.\n\n" }, { "category": "Radiology", "chartdate": "2158-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237560, "text": " 5:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change. Thanks.\n Admitting Diagnosis: ABDMOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p ex lap for pneumoperitoneum.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post ex lap, to look for pneumoperitoneum.\n\n TECHNIQUE: Erect portable chest view was reviewed in comparison with multiple\n prior chest radiographs, with most recent from .\n\n FINDINGS:\n\n Orogastric tube ends into the stomach. Right PICC line tip is at mid SVC.\n There are no interval changes in the lungs. Bibasilar atelectasis is similar.\n There is no evidence of pneumoperitoneum. No discrete lung opacities\n concerning for pneumonia. Pleural effusion if any is small on the right side\n and presumed. No Pulmonary edema or pneumoperitoneum.\n\n IMPRESSION: Minimal bibasilar atelectasis and presumed small right pleural\n effusion is unchanged. No pneumoperitoneum.\n\n" }, { "category": "Radiology", "chartdate": "2158-05-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1237355, "text": " 5:36 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 52cm Right DLPP \n Admitting Diagnosis: ABDMOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with new right picc needed for tpn\n REASON FOR THIS EXAMINATION:\n 52cm Right DLPP \n ______________________________________________________________________________\n WET READ: MDAg WED 6:05 PM\n R PICC coiled in the SVC, less likely going into the azygous given the course.\n The part extending superiorly is 6.3cm. Interval extubation.\n -MAgarwal d/ (IV RN) by phone at 6pm at time of discovery.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New right PICC line, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n new right-sided PICC line. The line is coiled in the upper SVC and needs to\n be re-positioned. There is no evidence of complications, notably no\n pneumothorax.\n\n In the interval, the patient has been extubated and the nasogastric tube\n remains unchanged in place. Unchanged size of the cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-05-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237219, "text": " 6:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation, ? et tube placement\n Admitting Diagnosis: ABDMOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p ex lap\n REASON FOR THIS EXAMINATION:\n s/p intubation, ? et tube placement\n ______________________________________________________________________________\n WET READ: MDAg TUE 8:46 PM\n ETT ends 5.5 cm above the carina. NGT coils in stomach although distal tip is\n not visualized. Lung volumes are lower than 4:40am. Bibasilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of an endotracheal tube with its tip approximately 5.5 cm above the\n carina. Nasogastric tube coils in the upper stomach then extends downward\n with the tip below the inferior margin of the image.\n\n Lung volumes are lower and there are atelectatic changes at the bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-05-24 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1237363, "text": " 6:43 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: R PICC coiled in SVC, pulled back 6cm, check PICC tip. \n Admitting Diagnosis: ABDMOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with new PICC\n REASON FOR THIS EXAMINATION:\n R PICC coiled in SVC, pulled back 6cm, check PICC tip. #\n ______________________________________________________________________________\n WET READ: MDAg WED 7:17 PM\n Limited assessment of R PICC tip due to low lung volumes and pt position. The\n tip projects over the right atrium on this single view. If pulled back 2cm, it\n will be safely in the mid-low SVC.\n -MAgarwal d/ by phone at 7:15pm .\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n New PICC line that was re-positioned.\n\n COMPARISON: , 5:24 p.m.\n\n FINDINGS: Limited assessment of the right PICC line due to low lung volumes\n and patient position. The tip projects over the right atrium on this single\n view. This could be pulled back by approximately 2 cm.\n\n Unchanged size of the cardiac silhouette. Unchanged presence of moderate\n retrocardiac atelectasis. Unchanged course of the nasogastric tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-05-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237408, "text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change.\n Admitting Diagnosis: ABDMOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p ex lap.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post ex lap, assess for interval change.\n\n COMPARISON: Portable chest radiograph from .\n\n TECHNIQUE: NG tube and right PICC line are unchanged in position. Since the\n most recent prior radiograph, there has been slight improvement in\n retrocardiac opacity, likley atelectasis. Mild pulmonary edema is stable.\n There is no focal consolidation, pleural effusion or pneumothorax. Cardiac\n silhouette is stable. Lung volumes are low.\n\n IMPRESSION: Stable mild pulmonary vascular congestion. Slight improvement in\n retrocardiac opacity.\n\n" } ]

[ { "category": "Echo", "chartdate": "2175-07-10 00:00:00.000", "description": "Report", "row_id": 66332, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Hypotension.\nHeight: (in) 69\nWeight (lb): 175\nBSA (m2): 1.95 m2\nBP (mm Hg): 98/46\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 11:44\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. IVC dilated (>2.1cm) with\n<50% decrease with sniff (estimated RA pressure (>=15 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severe\nglobal LV hypokinesis. Estimated cardiac index is depressed (<2.0L/min/m2). No\nLV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid\ninferolateral - akinetic;\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis. [Intrinsic RV systolic function likely more depressed given the\nseverity of TR].\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild to moderate\n(+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate (2+)\nMR. [Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Severe [4+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation. The patient is\nin a ventricularly paced rhythm.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. The\nestimated right atrial pressure is at least 15 mmHg. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is moderately dilated.\nThere is severe global left ventricular hypokinesis (LVEF = 20 %). No masses\nor thrombi are seen in the left ventricle. The right ventricular cavity is\nmoderately dilated with moderate global free wall hypokinesis. [Intrinsic\nright ventricular systolic function is likely more depressed given the\nseverity of tricuspid regurgitation.] The ascending aorta is mildly dilated.\nThe aortic valve leaflets are moderately thickened. Mild to moderate (+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] Severe [4+] tricuspid regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. Significant pulmonic\nregurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: Biventricular cavity enlargement with regional and global systolic\ndysfunction c/w multivessel CAD or other diffuse process. Pulmonary artery\nhypertension. At least moderate mitral regurgitation. Severe tricuspid\nregurgitation. Mild-moderate aortic regurgtiation. Dilated ascending aorta.\nCompared with the prior study (images reviewed) of , the right\nventricular cavity is more dilated with more prominent free wall hypokinesis,\nthe severity of TR is increased, and the estimated PA systolic pressure is\nlower (likely due to progressive RV dysfunction).\n\n\n" }, { "category": "ECG", "chartdate": "2175-07-09 00:00:00.000", "description": "Report", "row_id": 139001, "text": "Atrial demand pacing. Left axis deviation. Inferior wall myocardial\ninfarction, likely old. Poor R wave progression of uncertain significance.\nIntraventricular conduction delay and diffuse non-specific ST-T wave\nabnormalities. Compared to tracing #1 more atrial pacing is now seen.\nIncreased R wave in leads V3-V5 may reflect lead placement. Otherwise, no\ndiagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2175-07-20 00:00:00.000", "description": "Report", "row_id": 138999, "text": "Sinus rhythm. Occasional ventricular premature contraction. Occasional\natrially paced rhythm. Borderline left axis deviation. Intraventricular\nconduction defect. Non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of significant tachycardia has resolved. Occasional\natrially paced rhythm as well as ventricular premature contractions are new.\n\n\n" }, { "category": "ECG", "chartdate": "2175-07-14 00:00:00.000", "description": "Report", "row_id": 139000, "text": "Sinus tachycardia. Incomplete left bundle-branch block. Compared to the\nprevious tracing atrial pacing is no longer seen.\n\n" }, { "category": "ECG", "chartdate": "2175-07-09 00:00:00.000", "description": "Report", "row_id": 139002, "text": "Predominantly sinus rhythm versus ectopic atrial rhythm with atrial premature\ncontractions and one apparently atrial paced beat. Left axis deviation. Prior\ninferior myocardial infarction. Possible anterior wall myocardial infarction\nof indeterminate age. Intraventricular conduction defect. Diffuse\nnon-specific ST-T wave abnormalities. Compared to the previous tracing\nof atrial fibrillation has been replaced by what appears to be\npredominantly sinus or ectopic atrial rhythm. ST-T wave abnormalities are less\nmarked in leads V5 and V6. Clinical correlation and repeat tracing are\nsuggested.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2175-07-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1245533, "text": " 8:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pna,chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with sob\n REASON FOR THIS EXAMINATION:\n ?pna,chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old male with shortness of breath.\n\n COMPARISONS: .\n\n FINDINGS: Lungs are well expanded with improved aeration at the left base.\n Mild-to-moderate cardiomegaly is slightly improved with no appreciable\n residual pulmonary edema. No pleural effusion or pneumothorax.\n Pacemaker/defibrillator is in unchanged position.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2113-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1240935, "text": " 2:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change.\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with likely aspiration pneumonia. Now extubated, but\n requiring non-invasive ventilaton, spiking feves. Eval for interval change.\n REASON FOR THIS EXAMINATION:\n Eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Likely aspiration pneumonia, no extubation, spiking fevers.\n Evaluation for interval changes.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there are bilateral newly\n appeared extensive parenchymal opacities, notably in the perihilar areas and\n at the lung bases. The opacities are slightly more severe on the left than on\n the right. There is unchanged evidence of cardiomegaly. Signs of\n interstitial fluid overload are absent. In particular, there is no\n interstitial thickening and no pleural effusions.\n\n Overall, the distribution and morphology of the changes are more likely\n reflecting pneumonia than pulmonary edema.\n\n At the time of observation and dictation, 9:07 a.m., the referring physician,\n . , was paged for notification and the findings were subsequently\n discussed over the telephone.\n\n\n" }, { "category": "Radiology", "chartdate": "2113-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1240889, "text": " 1:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with hx aspiration pna\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of aspiration, evaluation for interval change, history of\n pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated and the nasogastric tube has been removed. The right central venous\n access line remains unchanged. The pre-existing large predominantly perihilar\n left-sided opacity has substantially decreased in extent. A minimal perihilar\n right opacity and a relatively large retrocardiac atelectasis persist. In\n addition, there is unchanged mild-to-moderate cardiomegaly with minimal signs\n of fluid overload. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2113-07-06 00:00:00.000", "description": "LP HUMERUS (AP & LAT) LEFT PORT", "row_id": 1240936, "text": " 2:20 AM\n HUMERUS (AP & LAT) LEFT PORT Clip # \n Reason: Please eval for displaced fx.\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with left proximal humeral fracture, appeared non-displaced\n on OSH film, but patient now with slightly more swelling. Please eval for\n displaced fx.\n REASON FOR THIS EXAMINATION:\n Please eval for displaced fx.\n ______________________________________________________________________________\n FINAL REPORT\n LEFT HUMERUS RADIOGRAPHS DATED .\n\n CLINICAL INDICATION: 53-year-old woman with left proximal humeral fracture,\n appeared nondisplaced on outside hospital film, now slightly more swelling.\n Evaluate for displaced fracture.\n\n COMPARISON: Chest radiograph from and .\n\n FINDINGS:\n\n There is an acute comminuted fracture involving the proximal left humerus\n surgical neck with mild posterior subluxation of dominant distal fracture\n fragment subluxed posteriorly by approximately two cortical widths and\n adjacent soft tissue swelling. Fracture lines on oblique radiograph appears to\n extend towards the greater tuberosity. The glenohumeral articulation appears\n grossly maintained on current limited views. The remaining mid-to-distal\n diaphysis of the humerus is grossly intact. Acromioclavicular joint\n demonstrated mild degenerative changes.\n\n IMPRESSION:\n\n Proximal left humerus comminuted fracture involving surgical neck with mild\n subluxation posteriorly of distal fracture fragment approximately two cortical\n widths with fracture line extension also extending towards greater tuberosity.\n Glenohumeral articulation is maintained.\n\n" }, { "category": "Radiology", "chartdate": "2113-07-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1240886, "text": " 1:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for bleeding, acute intracranial process.\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with recent fall, now with AMS. Please eval for bleeding,\n acute intracranial process.\n REASON FOR THIS EXAMINATION:\n Please eval for bleeding, acute intracranial process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST, .\n\n HISTORY: 53-year-old female with recent fall, now with altered mental status;\n evaluate for bleeding or other acute intracranial process.\n\n TECHNIQUE: Contiguous 5-mm axial MDCT sections were obtained from the skull\n base to the vertex and viewed in brain and bone window on the workstation.\n\n FINDINGS: There are no comparison studies on record. There is no significant\n abnormality of the extracalvarial soft tissues, and no underlying skull\n fracture is seen. There is no intra- or extra-axial hemorrhage, the midline\n structures are in the midline and the ventricles and cisterns are normal in\n size and configuration, with slight asymmetric prominence of all components of\n the right lateral ventricle, likely congenital/developmental. There is\n mucosal thickening involving scattered anterior ethmoidal air cells,\n bilaterally, which appears more marked since the sinus CT of . The\n remaining visualized paranasal sinuses, as well as the mastoid air cells and\n middle ear cavities are clear.\n\n IMPRESSION: No evidence of acute intracranial injury, and no skull fracture.\n\n" }, { "category": "Radiology", "chartdate": "2113-07-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1241016, "text": " 2:37 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: r dl power picc 35cm iv \n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r dl power picc 35cm iv \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old woman with right-sided PICC line.\n\n COMPARISONS: CXR 2:00 a.m.\n\n FINDINGS: A right-sided PICC line has been inserted with the tip extending\n cranially in the internal jugular vein. Lung volumes are low. Moderate\n pulmonary edema may be slightly improved since 2:00 a.m. Moderate\n cardiomegaly is unchanged.\n\n IMPRESSION: Right-sided PICC line extending cranially up the internal jugular\n vein.\n\n Findings were communicated with , the IV nurse via telephone on .\n\n" }, { "category": "Radiology", "chartdate": "2113-07-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1240791, "text": " 6:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for change in line placement and ET tube since t\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman just transfered from OSH, intubated, CVL in place, question\n of aspiration pneumonia at OSH.\n REASON FOR THIS EXAMINATION:\n Please eval for change in line placement and ET tube since transfer as well as\n evidence of pneumonia\n ______________________________________________________________________________\n WET READ: SHSf TUE 8:12 PM\n ETT is low in trachea 1.6 cm above carina. NGT with side hole at level of GE\n junction can advance 5-10 cm. Bibasal opacities could reflect atelectasis\n though aspiration could have this appearance. Mild pulmonary edema and likely\n small bilateral effusions may be present. d/ \n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Transferred from outside hospital, intubated. Question\n pneumonia.\n\n Prior study available for comparison is .\n\n Mild-to-moderate cardiomegaly is stable. ET tube tip is low, 1.5 cm above the\n carina, can be withdraw couple of centimeters for more standard position. NG\n tube tip is in the stomach, but the side hole is at the EG junction and should\n be advanced for more standard position. Right IJ catheter tip is at the\n cavoatrial junction. Left perihilar and lower lobe opacities are worrisome\n for aspiration given the clinical concern. There is mild vascular congestion.\n There is no pneumothorax. If any, there is a small left pleural effusion.\n\n Findings were discussed by Dr. with Dr. at 8:10 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2113-07-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241065, "text": " 2:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Is there development of effusions or significant change in i\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with admission for pneumonia and hypoxia extubated,\n infiltrates looking worse yesterday. CXR to eval for development of effusions.\n REASON FOR THIS EXAMINATION:\n Is there development of effusions or significant change in infiltrates?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Admission for pneumonia and hypoxia. Evaluation.\n\n COMPARISON: .\n\n FINDINGS: Compared to the previous radiograph, there is a slight tendency to\n increased consolidation formation in the left lung. The massive bilateral\n parenchymal opacities, likely representing a combination of pneumonia and\n pulmonary edema are overall unchanged. Unchanged borderline cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2113-07-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1241271, "text": " 3:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for PRES, any intracranial abnormality to explai\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with h/o ESRD on immunosupression, with persistent AMS -\n consern for PRES from sirolimus vs. encephalitis, cannot tolerate MRI. Please\n eval for PRES, any intracranial abnormality to explain AMS.\n REASON FOR THIS EXAMINATION:\n Please eval for PRES, any intracranial abnormality to explain AMS.\n CONTRAINDICATIONS for IV CONTRAST:\n Renal disease\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status, concern for PRES. Unable to tolerate MRI.\n\n COMPARISON: CT head exam available from .\n\n TECHNIQUE: MDCT-acquired 5-mm axial images of the head were obtained without\n the use of IV contrast.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass\n effect, or large vascular territorial infarction. There is no shift of\n normally midline structures. The middle ear cavities and mastoid air cells\n are clear. There is mild mucosal thickening within the anterior ethmoid air\n cells (2:9).\n\n IMPRESSION: No acute intracranial process. This examination is unchanged\n since .\n\n Note on attending review:\n Study is limited due to motion and noise. No large hypodense areas are noted\n in the brain. Followup as clinically indicated for changes.\n\n" }, { "category": "Radiology", "chartdate": "2113-07-06 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1240948, "text": " 7:20 AM\n PORTABLE ABDOMEN Clip # \n Reason: Please assess for obstruction, perforation.\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with worsening nausea, abdominal discomfort. Please assess\n for obstruction, perforation.\n REASON FOR THIS EXAMINATION:\n Please assess for obstruction, perforation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old woman with worsening nausea, abdominal discomfort.\n Assess for obstruction, perforation.\n\n COMPARISONS: CT abdomen and pelvis without contrast from .\n\n FINDINGS: There is air within loops of small bowel and large bowel in a\n nonspecific pattern without evidence of obstruction or free air. There is\n scoliosis of the spine with dextroconcave curvature in the thoracolumbar\n region. The remainder of the osseous structures are unremarkable. Clips are\n seen within the pelvis.\n\n IMPRESSION: Air within small and large bowel is nonspecific. No evidence of\n obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2113-07-07 00:00:00.000", "description": "LP SHOULDER 2-3 VIEWS NON TRAUMA LEFT PORT", "row_id": 1241088, "text": " 8:43 AM\n SHOULDER VIEWS NON TRAUMA LEFT PORT Clip # \n Reason: please complete AP and lateral shoulder views to evaluate ex\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with humerus fracture\n REASON FOR THIS EXAMINATION:\n please complete AP and lateral shoulder views to evaluate extent of fracture\n more clearly\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left shoulder, three views, .\n\n CLINICAL HISTORY: 53-year-old woman with humerus fracture.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is a fracture involving the surgical neck of the right humerus. A\n minimally displaced lesser tuberosity fracture fragment is also seen. There\n is no glenohumeral joint dislocation. There is prominent soft tissue\n swelling. There is a pleural effusion and prominence of the pulmonary\n interstitial markings, likely due to fluid overload and better assessed on the\n chest radiographs performed earlier today.\n\n" }, { "category": "Radiology", "chartdate": "2113-07-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241481, "text": " 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Is there evidence of worsening infiltrates or new effusions?\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with admission to MICU for significant hypoxia and pneumonia,\n had been improving, now WBC up today, cough worse and blood tinged, and more\n agitated.\n REASON FOR THIS EXAMINATION:\n Is there evidence of worsening infiltrates or new effusions?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:06 A.M., \n\n HISTORY: 53-year-old woman with a significant hypoxia and pneumonia, white\n count up, cough worse and blood tinged.\n\n IMPRESSION: AP chest compared to through 27:\n\n There is still substantial left perihilar opacification, but there has been\n improvement in more diffuse pulmonary findings, probably edema, now receding.\n Concurrent pneumonia may well be present but is not worsening. Moderate\n cardiomegaly is stable. Nasogastric tube passes into the stomach and out of\n view. Pleural effusion is small on the right, if any. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2113-07-11 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1241538, "text": " 12:51 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for intracranial pathology that could explai\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n Contrast: PROHANCE Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with aspiration pneumonia and altered mental status, seizures\n on EEG, elevated opening pressure on LP\n REASON FOR THIS EXAMINATION:\n please evaluate for intracranial pathology that could explain seizures and/or\n altered mental status, please also evaluate for PRES\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with aspiration pneumonia and altered mental\n status, seizures on EEG, elevated opening pressure on lumbar puncture; for\n further evaluation.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility, and diffusion\n axial images of the brain were acquired before gadolinium. T1 axial and\n MP-RAGE sagittal images acquired following gadolinium. The post-gadolinium\n images are limited by motion.\n\n FINDINGS: There is no acute infarct seen on diffusion images. There is no\n mass effect, midline shift, or hydrocephalus. There is no evidence of chronic\n or acute blood products. Following gadolinium, the limited images demonstrate\n no obvious areas of enhancement.\n\n IMPRESSION: No significant abnormalities on MRI of the brain with and without\n gadolinium with somewhat limited post-gadolinium images by motion. Fluid in\n both bilateral mastoid air cells.\n\n\n" }, { "category": "Radiology", "chartdate": "2113-07-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241319, "text": " 4:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with h/o aspiration, pneumonia here with persistent o2\n requirement, altered mental status. Please eval for interval change.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 53-year-old woman with history of aspiration and pneumonia. Altered\n mental status.\n\n FINDINGS: Comparison is made to the previous study from .\n\n There is a feeding tube whose distal tip is not well seen on the field of\n view. There is marked cardiomegaly. There are extensive airspace opacities\n throughout both lung fields likely related to pulmonary edema. Underlying\n infection is not entirely excluded. No pneumothoraces are seen.\n\n" }, { "category": "Radiology", "chartdate": "2113-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241052, "text": " 7:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for NG tube placement\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with NG tube placement\n REASON FOR THIS EXAMINATION:\n please eval for NG tube placement\n ______________________________________________________________________________\n WET READ: 9:12 PM\n NG into stomach and out of view. similar appearance to moderate pulmonary\n edema. PICC removed\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n FINDINGS: Two portable semi-erect chest radiographs were obtained. NG tube\n passes into the stomach and extends inferiorly out of the field of view. A\n right-sided PICC line has been pulled back into the axillary vein. Low lung\n volumes and extensive bilateral left greater than right alveolar opacities are\n unchanged. Moderate cardiomegaly is similar.\n\n IMPRESSION:\n 1. NG tube below the diaphragm.\n 2. Right-sided PICC line has been pulled back to the right axillary vein.\n 3. The predominant pattern of stable left greater than right diffuse alveolar\n opacities indicates moderate CHF. Underlying infection cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2113-07-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1241362, "text": " 7:45 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: worsening pna\n Admitting Diagnosis: S/P KIDNEY;ACUTE RESPIRATORY FAILURE; ? MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with aspiration pneumonia, worsening tachypnea\n REASON FOR THIS EXAMINATION:\n worsening pna\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 53-year-old woman with aspiration pneumonia and worsening\n tachypnea.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is a nasogastric tube whose distal tip and side port are below the\n gastroesophageal junction. There is unchanged cardiomegaly and diffuse\n airspace opacities and prominent pulmonary interstitial markings consistent\n with fluid overload. This likely represents pulmonary edema, however,\n overlying infection is not excluded.\n\n" }, { "category": "ECG", "chartdate": "2113-07-19 00:00:00.000", "description": "Report", "row_id": 161922, "text": "Sinus rhythm. Mild Q-T interval prolongation. T wave abnormalities. Late\nR wave progression. Consider anterior myocardial infarction, age undetermined.\nSince the previous tracing of probably no significant change.\n\n" }, { "category": "ECG", "chartdate": "2113-07-18 00:00:00.000", "description": "Report", "row_id": 161923, "text": "Sinus rhythm. Borderline Q-T interval prolongation. Non-specific ST segment\nchanges. Compared to the previous tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2113-07-09 00:00:00.000", "description": "Report", "row_id": 161924, "text": "Sinus rhythm. Mild Q-T interval prolongation. Minor T wave abnormalities.\nSince the previous tracing of T wave abnormalities are more prominent.\n\n" }, { "category": "ECG", "chartdate": "2113-07-06 00:00:00.000", "description": "Report", "row_id": 161925, "text": "Sinus rhythm. Mild Q-T interval prolongation. Compared to the previous\ntracing of no interim diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2113-07-04 00:00:00.000", "description": "Report", "row_id": 161926, "text": "Sinus rhythm. Q-T interval prolongation, similar to that recorded on .\nNo apparent diagnostic interim change.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2107-08-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 335339, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management. Electrolyte imbalances\n managed with KCL repletion, Mg repletion, & Multiple nacl boluses.\n C/O today ().\n Electrolyte & fluid disorder related to poor oral intake / lHCTZ./ ETOH\n abuse.\n Assessment:\n Hyponatremia as evidenced from lab results. Patient alert, oriented\n X3. Na 126, K : 3.9, Mg : 2.1\n Action:\n .Na Cl with 40 meq KCL started @ 250 ml /hr for 2 L. Electrolytes\n sent at 0900 hrs\n Response:\n Patient remains alert, oriented X3. Mg & K within normal range. Na up\n to 126 from 114.\n Plan:\n Will closely monitor her electrolye closely. Continue monitoring her\n EKG & mental status. Next electrolytes at 1730 hrs.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Remains with the patient. Encouraged the patient to use call light for\n assistance.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercize.\n Plan:\n Cont to monitor her sats closely. If needed may start O2 per NC.\n" }, { "category": "General", "chartdate": "2107-08-06 00:00:00.000", "description": "Generic Note", "row_id": 335383, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management. Electrolyte imbalances\n managed with KCL repletion, Mg repletion, & Multiple nacl boluses.\n C/O today ().\n Electrolyte & fluid disorder related to poor oral intake / lHCTZ./ ETOH\n abuse.\n Assessment:\n Hyponatremia as evidenced from lab results. Patient alert, oriented\n X3. Na 126, K : 3.9, Mg : 2.1\n Action:\n .Na Cl with 40 meq KCL started @ 250 ml /hr for 2 L. Electrolytes\n sent at 0900 hrs\n Response:\n Patient remains alert, oriented X3. Mg & K within normal range. Na up\n to 126 from 114.\n Plan:\n Will closely monitor her electrolye closely. Continue monitoring her\n EKG & mental status. Next electrolytes at 1730 hrs.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Remains with the patient. Encouraged the patient to use call light for\n assistance.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercize.\n Plan:\n Cont to monitor her sats closely. If needed may start O2 per NC.\n" }, { "category": "Physician ", "chartdate": "2107-08-06 00:00:00.000", "description": "Physician Resident/Attending Progress Note", "row_id": 335338, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 09:30 AM\n EKG - At 01:46 AM\n Allergies:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 71 (57 - 82) bpm\n BP: 105/42(56) {99/19(37) - 160/90(103)} mmHg\n RR: 23 (14 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 4,535 mL\n 3,054 mL\n PO:\n 200 mL\n 170 mL\n TF:\n IVF:\n 3,335 mL\n 2,884 mL\n Blood products:\n Total out:\n 800 mL\n 450 mL\n Urine:\n 800 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,735 mL\n 2,604 mL\n Respiratory support\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Gen: Well appearing adult female, no acute distress.\n HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented.\n Neck: Supple, without adenopathy or JVD. No tenderness with palpation.\n Chest: CTAB anterior and posterior.\n Cor: Normal S1, S2. RRR. No murmurs appreciated.\n Abdomen: Soft, non-tender and non-distended. +BS, no HSM.\n Extremity: Warm, without edema. 2+ DP pulses bilat.\n Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all\n extremities. Sensation intact grossly.\n Labs / Radiology\n 172 K/uL\n 12.0 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 86 mEq/L\n 122 mEq/L\n 34.3 %\n 6.9 K/uL\n [image002.jpg]\n 05:25 AM\n 09:47 AM\n 12:44 PM\n 04:27 PM\n 09:43 PM\n 04:08 AM\n WBC\n 5.4\n 6.9\n Hct\n 35.1\n 34.3\n Plt\n 189\n 172\n Cr\n 1.1\n 1.1\n 1.2\n 1.1\n 1.0\n Glucose\n 95\n 161\n 117\n 120\n 121\n 121\n Other labs: PT / PTT / INR:13.7/29.6/1.2, ALT / AST:14/67, Alk Phos / T\n Bili:142/1.6, Amylase / Lipase:32/, Differential-Neuts:68.7 %,\n Lymph:15.6 %, Mono:10.1 %, Eos:5.5 %, Albumin:4.3 g/dL, LDH:276 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 62yo woman w/ h/o HTN & CHF, h/o ETOH abuse (although she denies active\n use), who presents with fatigue, malaise, nausea, and is found to have\n multiple severe electrolyte abnormalities\nhyponatermia, hypokalemia,\n hypomagnesemia.\n # Hyponatremia: Suspect most likely hypovolemic hyponatremia occurring\n in the setting of poor PO intake, diuretic and EtOH use. Pt has\n responded well to repletion with NS.\n - Continue NS infusion\n - regular diet\n #Hypokalemia/Hypomag: As above, likely related to thiazide use and\n dehydration, as well as EtOH.\n - Continue aggressive repletion of both K and Mg, with understanding\n that control of K may be difficult to achieve until Mg is stable.\n #Dark colored urine: Noted by nursing staff this AM. Pt asymptomatic.\n Check UA.\n # H/o ETOH abuse: Pt reports abstinence for >mo. Will start empiric\n CIWA scale in case story not accurate.\n #CHF: appears to be euvolemic to hypovolemic at present\n - hold lasix, HCTZ, atenolol\n #Colitis:\n - Con't home meds\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n PICC Line - 09:30 AM\n Prophylaxis:\n DVT: heparin subq\n Stress ulcer: PO diet\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 61 yo woman with active EtOH abuse, CHF related to mitral\n regurgitation, who was admitted with Na 116. Hyponatremia thought\n due to HCTZ use and volume depletion.\n 24 hour events:\n 1) PICC placed overnight\n 2) received normal saline with improvement in Na 116 to 126\n Exam notable for Tm 98 BP 99 HR 87 RR 18 with sat 97 on RA . Labs\n notable for WBC6.9 K, HCT 34.3, Na 126, K+ 3.9 , Cr 1. Phos 1.9 Mg 1.9\n I/O 3735/800 (24 hrs)\n Comfortable. Not tremulous. Lungs clear. RRR, no m/r/g. +Bs, soft,\n nontender. No LE edema. R PICC site c/d/i.\n Agree with plan to\n 1) hyponatremia due to hypovolemia\n -improving with normal saline\n -can continue to follow Na q8hr\n -continue to hold HCTZ\n 2) hypophosphatemia and hypomagnesemia ?related to chronic alcohol\n abuse\n -replete electrolytes\n -continue to monitor on CIWA scale\n Stable to transfer to floor.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 60 min\n ------ Protected Section Addendum Entered By: , MD\n on: 15:53 ------\n" }, { "category": "Physician ", "chartdate": "2107-08-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 335321, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 09:30 AM\n EKG - At 01:46 AM\n Allergies:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 71 (57 - 82) bpm\n BP: 105/42(56) {99/19(37) - 160/90(103)} mmHg\n RR: 23 (14 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 4,535 mL\n 3,054 mL\n PO:\n 200 mL\n 170 mL\n TF:\n IVF:\n 3,335 mL\n 2,884 mL\n Blood products:\n Total out:\n 800 mL\n 450 mL\n Urine:\n 800 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,735 mL\n 2,604 mL\n Respiratory support\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Gen: Well appearing adult female, no acute distress.\n HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented.\n Neck: Supple, without adenopathy or JVD. No tenderness with palpation.\n Chest: CTAB anterior and posterior.\n Cor: Normal S1, S2. RRR. No murmurs appreciated.\n Abdomen: Soft, non-tender and non-distended. +BS, no HSM.\n Extremity: Warm, without edema. 2+ DP pulses bilat.\n Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all\n extremities. Sensation intact grossly.\n Labs / Radiology\n 172 K/uL\n 12.0 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 86 mEq/L\n 122 mEq/L\n 34.3 %\n 6.9 K/uL\n [image002.jpg]\n 05:25 AM\n 09:47 AM\n 12:44 PM\n 04:27 PM\n 09:43 PM\n 04:08 AM\n WBC\n 5.4\n 6.9\n Hct\n 35.1\n 34.3\n Plt\n 189\n 172\n Cr\n 1.1\n 1.1\n 1.2\n 1.1\n 1.0\n Glucose\n 95\n 161\n 117\n 120\n 121\n 121\n Other labs: PT / PTT / INR:13.7/29.6/1.2, ALT / AST:14/67, Alk Phos / T\n Bili:142/1.6, Amylase / Lipase:32/, Differential-Neuts:68.7 %,\n Lymph:15.6 %, Mono:10.1 %, Eos:5.5 %, Albumin:4.3 g/dL, LDH:276 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 62yo woman w/ h/o HTN & CHF, h/o ETOH abuse (although she denies active\n use), who presents with fatigue, malaise, nausea, and is found to have\n multiple severe electrolyte abnormalities\nhyponatermia, hypokalemia,\n hypomagnesemia.\n # Hyponatremia: Suspect most likely hypovolemic hyponatremia occurring\n in the setting of poor PO intake, diuretic and EtOH use. Pt has\n responded well to repletion with NS.\n - Continue NS infusion\n - regular diet\n #Hypokalemia/Hypomag: As above, likely related to thiazide use and\n dehydration, as well as EtOH.\n - Continue aggressive repletion of both K and Mg, with understanding\n that control of K may be difficult to achieve until Mg is stable.\n #Dark colored urine: Noted by nursing staff this AM. Pt asymptomatic.\n Check UA.\n # H/o ETOH abuse: Pt reports abstinence for >mo. Will start empiric\n CIWA scale in case story not accurate.\n #CHF: appears to be euvolemic to hypovolemic at present\n - hold lasix, HCTZ, atenolol\n #Colitis:\n - Con't home meds\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n PICC Line - 09:30 AM\n Prophylaxis:\n DVT: heparin subq\n Stress ulcer: PO diet\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2107-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 335195, "text": "Pt overnight very restless in the bed. c/o discomfort to bilateral\n lower extremeties w/2+ edema noted over last sev days at home. Also\n w/constant c/o pain at the bp cuff site.. mult interventions attempted,\n none successful w/pt removing cuff hourly. States she usually takes\n codeine for pain. Ordered and given overnight. Pt managed to disconnect\n her ivf x4 from her picc line, each time w/lots of ivf ;lost and\n requiring bed changes x4. Reminded pt to b e mindful of the lines and\n tubes attached, taped inb place, but somehow still manages to get them\n disconnected. Has been ok since her codeine at 0400.\n Electrolyte & fluid disorder, other\n Assessment:\n Conts to have electrolyte discturbance. Na and k repletion\n Action:\n Last bag of 3000 mls kcl infusing at 250cc/hr currently. Lytes pending\n from 0400\n Response:\n Electrolytes slowly improving\n Plan:\n Cont to monitor q4-6 hrs. ?? c/o to floor if el;ectrolytes better this\n am\n" }, { "category": "Physician ", "chartdate": "2107-08-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 335267, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 09:30 AM\n EKG - At 01:46 AM\n Allergies:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 71 (57 - 82) bpm\n BP: 105/42(56) {99/19(37) - 160/90(103)} mmHg\n RR: 23 (14 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 4,535 mL\n 3,054 mL\n PO:\n 200 mL\n 170 mL\n TF:\n IVF:\n 3,335 mL\n 2,884 mL\n Blood products:\n Total out:\n 800 mL\n 450 mL\n Urine:\n 800 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,735 mL\n 2,604 mL\n Respiratory support\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 12.0 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 86 mEq/L\n 122 mEq/L\n 34.3 %\n 6.9 K/uL\n [image002.jpg]\n 05:25 AM\n 09:47 AM\n 12:44 PM\n 04:27 PM\n 09:43 PM\n 04:08 AM\n WBC\n 5.4\n 6.9\n Hct\n 35.1\n 34.3\n Plt\n 189\n 172\n Cr\n 1.1\n 1.1\n 1.2\n 1.1\n 1.0\n Glucose\n 95\n 161\n 117\n 120\n 121\n 121\n Other labs: PT / PTT / INR:13.7/29.6/1.2, ALT / AST:14/67, Alk Phos / T\n Bili:142/1.6, Amylase / Lipase:32/, Differential-Neuts:68.7 %,\n Lymph:15.6 %, Mono:10.1 %, Eos:5.5 %, Albumin:4.3 g/dL, LDH:276 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n PICC Line - 09:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2107-08-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 335271, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 09:30 AM\n EKG - At 01:46 AM\n Allergies:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 71 (57 - 82) bpm\n BP: 105/42(56) {99/19(37) - 160/90(103)} mmHg\n RR: 23 (14 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 63 Inch\n Total In:\n 4,535 mL\n 3,054 mL\n PO:\n 200 mL\n 170 mL\n TF:\n IVF:\n 3,335 mL\n 2,884 mL\n Blood products:\n Total out:\n 800 mL\n 450 mL\n Urine:\n 800 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,735 mL\n 2,604 mL\n Respiratory support\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 12.0 g/dL\n 121 mg/dL\n 1.0 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 86 mEq/L\n 122 mEq/L\n 34.3 %\n 6.9 K/uL\n [image002.jpg]\n 05:25 AM\n 09:47 AM\n 12:44 PM\n 04:27 PM\n 09:43 PM\n 04:08 AM\n WBC\n 5.4\n 6.9\n Hct\n 35.1\n 34.3\n Plt\n 189\n 172\n Cr\n 1.1\n 1.1\n 1.2\n 1.1\n 1.0\n Glucose\n 95\n 161\n 117\n 120\n 121\n 121\n Other labs: PT / PTT / INR:13.7/29.6/1.2, ALT / AST:14/67, Alk Phos / T\n Bili:142/1.6, Amylase / Lipase:32/, Differential-Neuts:68.7 %,\n Lymph:15.6 %, Mono:10.1 %, Eos:5.5 %, Albumin:4.3 g/dL, LDH:276 IU/L,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 62yo woman w/ h/o HTN & CHF, h/o ETOH abuse (although she denies active\n use), who presents with fatigue, malaise, nausea, and is found to have\n multiple severe electrolyte abnormalities\nhyponatermia, hypokalemia,\n hypomagnesemia.\n # Hyponatremia: Suspect most likely hypovolemic hyponatremia occurring\n in the setting of poor PO intake, diuretic and EtOH use. Pt has\n responded well to repletion with NS.\n - Recheck lytes & adjust tx based on results. Get PICC for addn\n access\n - Q2h Na checks\n #Hypokalemia/Hypomag: As above, likely related to thiazide use and\n dehydration, as well as EtOH.\n - Continue aggressive repletion of both K and Mg, with understanding\n that control of K may be difficult to achieve until Mg is stable.\n # H/o ETOH abuse: Pt reports abstinence for >mo. Will start empiric\n CIWA scale in case story not accurate.\n #CHF: appears to be euvolemic to hypovolemic at present\n - hold lasix, HCTZ, atenolol\n #Colitis:\n - Con't home meds\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n PICC Line - 09:30 AM\n Prophylaxis:\n DVT: heparin subq\n Stress ulcer: PO diet\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2107-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 335112, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management.\n Electrolyte & fluid disorder (hyponatremia, hypomagnesemia, hypokalemia\n ) related to poor oral intake / lHCTZ.\n Assessment:\n Hyponatremia, hypomagnesemia, hypokalemia as evidenced from lab\n results. Patient alert, oriented X3. EKG sinus brady at times with\n rare PVC\ns noted. Na 117, K : 2.6, Mg : 1.1\n Action:\n Nacl 500 ml fluid bolus given X1. Na Cl with 40 meq KCL started @\n 160 ml /hr for 2 L. 40 meq KCL IV repleted. 6 gm Mg replaced IV. Urine\n sent for osmolality & Na . ( straight cath done to obtain sample).\n Response:\n Patient remains alert, oriented X3. Lab sent at 1630 hrs, waiting for\n result.\n Plan:\n Will closely monitor her electrolye closely. Continue monitoring her\n EKG & mental status.\n" }, { "category": "Nursing", "chartdate": "2107-08-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 335435, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management. Electrolyte imbalances\n managed with KCL repletion, Mg repletion, & Multiple nacl boluses.\n C/O today ().\n Electrolyte & fluid disorder related to poor oral intake / lHCTZ./ ETOH\n abuse.\n Assessment:\n Hyponatremia as evidenced from lab results. Patient alert, oriented\n X3. Na 126, K : 3.9, Mg : 2.1\n Action:\n Na Cl with 40 meq KCL started @ 250 ml /hr for 2 L.\n Response:\n Patient remains alert, oriented X3. Mg & K within normal range. Na up\n to 125 from 114.\n Plan:\n Will monitor electrolyes closely.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Encouraged the patient to use call light for assistance, CDB.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercise.\n Plan:\n Encourage CDB. Adequate rest periods in between activity.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n HYPONATREMIA\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 94.3 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Precautions:\n PMH: Anemia\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: Afib, ulcerative colitis, ventral hernia, ETOH\n abuse, domestic violence, hypercholesterolemia, mult. environmental\n allergies\n Surgery / Procedure and date: s/p ventral hernia repair, s/p back\n surgery\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:147\n D:80\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Room Air\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 6,293 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 125 mEq/L\n 04:48 PM\n Potassium:\n 4.4 mEq/L\n 04:48 PM\n Chloride:\n 91 mEq/L\n 04:48 PM\n CO2:\n 23 mEq/L\n 04:48 PM\n BUN:\n 14 mg/dL\n 04:48 PM\n Creatinine:\n 0.9 mg/dL\n 04:48 PM\n Glucose:\n 141 mg/dL\n 04:48 PM\n Hematocrit:\n 34.3 %\n 04:08 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Black cotton pants, beige floral top.\n Wallet / Money: No money / wallet\n Cash / Credit cards sent home with: Family\n Jewelry: Engagement ring and wedding band on pt\ns L finger\n Transferred from: MICU 7\n Transferred to: 5\n Date & time of Transfer: @ 2330\n" }, { "category": "Nursing", "chartdate": "2107-08-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 335421, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management. Electrolyte imbalances\n managed with KCL repletion, Mg repletion, & Multiple nacl boluses.\n C/O today ().\n Electrolyte & fluid disorder related to poor oral intake / lHCTZ./ ETOH\n abuse.\n Assessment:\n Hyponatremia as evidenced from lab results. Patient alert, oriented\n X3. Na 126, K : 3.9, Mg : 2.1\n Action:\n .Na Cl with 40 meq KCL started @ 250 ml /hr for 2 L. Electrolytes\n sent at 0900 hrs\n Response:\n Patient remains alert, oriented X3. Mg & K within normal range. Na up\n to 126 from 114.\n Plan:\n Will monitor electrolye closely. Continue monitoring mental status.\n Last K 4.4 and Na 125\n goal NA is >120.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Remains with the patient. Encouraged the patient to use call light for\n assistance.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercise.\n Plan:\n Encourage CDB. Adequate rest periods in between activity.\n" }, { "category": "Nursing", "chartdate": "2107-08-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 335422, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management. Electrolyte imbalances\n managed with KCL repletion, Mg repletion, & Multiple nacl boluses.\n C/O today ().\n Electrolyte & fluid disorder related to poor oral intake / lHCTZ./ ETOH\n abuse.\n Assessment:\n Hyponatremia as evidenced from lab results. Patient alert, oriented\n X3. Na 126, K : 3.9, Mg : 2.1\n Action:\n .Na Cl with 40 meq KCL started @ 250 ml /hr for 2 L. Electrolytes\n sent at 0900 hrs\n Response:\n Patient remains alert, oriented X3. Mg & K within normal range. Na up\n to 126 from 114.\n Plan:\n Will monitor electrolye closely. Continue monitoring mental status.\n Last K 4.4 and Na 125\n goal NA is >120.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Remains with the patient. Encouraged the patient to use call light for\n assistance.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercise.\n Plan:\n Encourage CDB. Adequate rest periods in between activity.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n HYPONATREMIA\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 94.3 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Precautions:\n PMH: Anemia\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: Afib, ulcerative colitis, ventral hernia, ETOH\n abuse, domestic violence, hypercholesterolemia, mult. environmental\n allergies\n Surgery / Procedure and date: s/p ventral hernia repair, s/p back\n surgery\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:147\n D:80\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 6,293 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 125 mEq/L\n 04:48 PM\n Potassium:\n 4.4 mEq/L\n 04:48 PM\n Chloride:\n 91 mEq/L\n 04:48 PM\n CO2:\n 23 mEq/L\n 04:48 PM\n BUN:\n 14 mg/dL\n 04:48 PM\n Creatinine:\n 0.9 mg/dL\n 04:48 PM\n Glucose:\n 141 mg/dL\n 04:48 PM\n Hematocrit:\n 34.3 %\n 04:08 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2107-08-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 335423, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management. Electrolyte imbalances\n managed with KCL repletion, Mg repletion, & Multiple nacl boluses.\n C/O today ().\n Electrolyte & fluid disorder related to poor oral intake / lHCTZ./ ETOH\n abuse.\n Assessment:\n Hyponatremia as evidenced from lab results. Patient alert, oriented\n X3. Na 126, K : 3.9, Mg : 2.1\n Action:\n .Na Cl with 40 meq KCL started @ 250 ml /hr for 2 L. Electrolytes\n sent at 0900 hrs\n Response:\n Patient remains alert, oriented X3. Mg & K within normal range. Na up\n to 126 from 114.\n Plan:\n Will monitor electrolye closely. Continue monitoring mental status.\n Last K 4.4 and Na 125\n goal NA is >120.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Remains with the patient. Encouraged the patient to use call light for\n assistance.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercise.\n Plan:\n Encourage CDB. Adequate rest periods in between activity.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n HYPONATREMIA\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 94.3 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Precautions:\n PMH: Anemia\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: Afib, ulcerative colitis, ventral hernia, ETOH\n abuse, domestic violence, hypercholesterolemia, mult. environmental\n allergies\n Surgery / Procedure and date: s/p ventral hernia repair, s/p back\n surgery\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:147\n D:80\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Room Air\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 6,293 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 125 mEq/L\n 04:48 PM\n Potassium:\n 4.4 mEq/L\n 04:48 PM\n Chloride:\n 91 mEq/L\n 04:48 PM\n CO2:\n 23 mEq/L\n 04:48 PM\n BUN:\n 14 mg/dL\n 04:48 PM\n Creatinine:\n 0.9 mg/dL\n 04:48 PM\n Glucose:\n 141 mg/dL\n 04:48 PM\n Hematocrit:\n 34.3 %\n 04:08 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7\n Transferred to: 5\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2107-08-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 335425, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management. Electrolyte imbalances\n managed with KCL repletion, Mg repletion, & Multiple nacl boluses.\n C/O today ().\n Electrolyte & fluid disorder related to poor oral intake / lHCTZ./ ETOH\n abuse.\n Assessment:\n Hyponatremia as evidenced from lab results. Patient alert, oriented\n X3. Na 126, K : 3.9, Mg : 2.1\n Action:\n .Na Cl with 40 meq KCL started @ 250 ml /hr for 2 L. Electrolytes\n sent at 0900 hrs\n Response:\n Patient remains alert, oriented X3. Mg & K within normal range. Na up\n to 126 from 114.\n Plan:\n Will monitor electrolye closely. Continue monitoring mental status.\n Last K 4.4 and Na 125\n goal NA is >120.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Remains with the patient. Encouraged the patient to use call light for\n assistance.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercise.\n Plan:\n Encourage CDB. Adequate rest periods in between activity.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n HYPONATREMIA\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 94.3 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Precautions:\n PMH: Anemia\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: Afib, ulcerative colitis, ventral hernia, ETOH\n abuse, domestic violence, hypercholesterolemia, mult. environmental\n allergies\n Surgery / Procedure and date: s/p ventral hernia repair, s/p back\n surgery\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:147\n D:80\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Room Air\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 6,293 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 125 mEq/L\n 04:48 PM\n Potassium:\n 4.4 mEq/L\n 04:48 PM\n Chloride:\n 91 mEq/L\n 04:48 PM\n CO2:\n 23 mEq/L\n 04:48 PM\n BUN:\n 14 mg/dL\n 04:48 PM\n Creatinine:\n 0.9 mg/dL\n 04:48 PM\n Glucose:\n 141 mg/dL\n 04:48 PM\n Hematocrit:\n 34.3 %\n 04:08 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Black cotton pants, beige floral top.\n Wallet / Money: No money / wallet\n Cash / Credit cards sent home with: Family\n Jewelry: Engagement ring and wedding band on pt\ns L finger\n Transferred from: MICU 7\n Transferred to: 5\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2107-08-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 335426, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management. Electrolyte imbalances\n managed with KCL repletion, Mg repletion, & Multiple nacl boluses.\n C/O today ().\n Electrolyte & fluid disorder related to poor oral intake / lHCTZ./ ETOH\n abuse.\n Assessment:\n Hyponatremia as evidenced from lab results. Patient alert, oriented\n X3. Na 126, K : 3.9, Mg : 2.1\n Action:\n Na Cl with 40 meq KCL started @ 250 ml /hr for 2 L.\n Response:\n Patient remains alert, oriented X3. Mg & K within normal range. Na up\n to 125 from 114.\n Plan:\n Will monitor electrolyes closely.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Encouraged the patient to use call light for assistance, CDB.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercise.\n Plan:\n Encourage CDB. Adequate rest periods in between activity.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n HYPONATREMIA\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 94.3 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Precautions:\n PMH: Anemia\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: Afib, ulcerative colitis, ventral hernia, ETOH\n abuse, domestic violence, hypercholesterolemia, mult. environmental\n allergies\n Surgery / Procedure and date: s/p ventral hernia repair, s/p back\n surgery\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:147\n D:80\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Room Air\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 6,293 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 125 mEq/L\n 04:48 PM\n Potassium:\n 4.4 mEq/L\n 04:48 PM\n Chloride:\n 91 mEq/L\n 04:48 PM\n CO2:\n 23 mEq/L\n 04:48 PM\n BUN:\n 14 mg/dL\n 04:48 PM\n Creatinine:\n 0.9 mg/dL\n 04:48 PM\n Glucose:\n 141 mg/dL\n 04:48 PM\n Hematocrit:\n 34.3 %\n 04:08 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Black cotton pants, beige floral top.\n Wallet / Money: No money / wallet\n Cash / Credit cards sent home with: Family\n Jewelry: Engagement ring and wedding band on pt\ns L finger\n Transferred from: MICU 7\n Transferred to: 5\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2107-08-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 335427, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management. Electrolyte imbalances\n managed with KCL repletion, Mg repletion, & Multiple nacl boluses.\n C/O today ().\n Electrolyte & fluid disorder related to poor oral intake / lHCTZ./ ETOH\n abuse.\n Assessment:\n Hyponatremia as evidenced from lab results. Patient alert, oriented\n X3. Na 126, K : 3.9, Mg : 2.1\n Action:\n Na Cl with 40 meq KCL started @ 250 ml /hr for 2 L.\n Response:\n Patient remains alert, oriented X3. Mg & K within normal range. Na up\n to 125 from 114.\n Plan:\n Will monitor electrolyes closely.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Encouraged the patient to use call light for assistance, CDB.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercise.\n Plan:\n Encourage CDB. Adequate rest periods in between activity.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n HYPONATREMIA\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 94.3 kg\n Daily weight:\n Allergies/Reactions:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Precautions:\n PMH: Anemia\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: Afib, ulcerative colitis, ventral hernia, ETOH\n abuse, domestic violence, hypercholesterolemia, mult. environmental\n allergies\n Surgery / Procedure and date: s/p ventral hernia repair, s/p back\n surgery\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:147\n D:80\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Room Air\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 6,293 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 125 mEq/L\n 04:48 PM\n Potassium:\n 4.4 mEq/L\n 04:48 PM\n Chloride:\n 91 mEq/L\n 04:48 PM\n CO2:\n 23 mEq/L\n 04:48 PM\n BUN:\n 14 mg/dL\n 04:48 PM\n Creatinine:\n 0.9 mg/dL\n 04:48 PM\n Glucose:\n 141 mg/dL\n 04:48 PM\n Hematocrit:\n 34.3 %\n 04:08 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Black cotton pants, beige floral top.\n Wallet / Money: No money / wallet\n Cash / Credit cards sent home with: Family\n Jewelry: Engagement ring and wedding band on pt\ns L finger\n Transferred from: MICU 7\n Transferred to: 5\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2107-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 335099, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management.\n Electrolyte & fluid disorder (hyponatremia, hypomagnesemia, hypokalemia\n ) related to poor oral intake / lHCTZ.\n Assessment:\n Hyponatremia, hypomagnesemia, hypokalemia as evidenced from lab\n results. Patient alert, oriented X3. EKG sinus brady at times with\n rare PVC\ns noted. Na 117, K : 2.6, Mg : 1.1\n Action:\n Nacl 500 ml fluid bolus given X1. Na Cl with 40 meq KCL started @\n 160 ml /hr for 2 L. 40 meq KCL IV repleted. 6 gm Mg replaced IV. Urine\n sent for osmolality & Na . ( straight cath done to obtain sample).\n Response:\n Patient remains alert, oriented X3. Lab sent at 1630 hrs, waiting for\n result.\n Plan:\n Will closely monitor her electrolye closely. Continue monitoring her\n EKG & mental status.\n" }, { "category": "Nursing", "chartdate": "2107-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 335091, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and HCTZ.\n Exposure to sick contacts with grandchildren having viral illness past\n week. at 0400 hrs presented to :ED with electrolye\n imbalances. Hemodynamically stable. Rx with NS approx 1L. Tranx to\n MICU for further management.\n Electrolyte & fluid disorder (hyponatremia, hypomagnesemia, hypokalemia\n ) related to poor oral intake / lHCTZ.\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Radiology", "chartdate": "2107-08-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1027838, "text": " 1:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with dyspnea x 1 week\n REASON FOR THIS EXAMINATION:\n ?PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with dyspnea for one week, evaluate for\n pneumonia or CHF.\n\n COMPARISON: .\n\n AP CHEST: Moderate cardiomegaly is unchanged. The aorta is tortuous. The\n lungs are clear without evidence of effusion, consolidation, or pneumothorax.\n\n IMPRESSION: Stable moderate cardiomegaly without evidence of CHF or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2107-08-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028440, "text": " 11:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for fluid overload\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with hyponatremia aggressively fluid replaced with wheezing\n and DOE who does not appear clincally fluid overloaded but want to r/o overload\n radiographically.\n REASON FOR THIS EXAMINATION:\n please assess for fluid overload\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc MON 3:02 PM\n PFI: Since , there is no volume overload. Moderate cardiomegaly is\n unchanged. Right PICC ends in mid-to-lower SVC.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMMENTS: 62-year-old woman with hyponatremia, aggressively fluid replaced\n with wheezing and DOE who does not appear clinically fluid overload but want\n to rule out overload radiographically.\n\n FINDINGS: There is no fluid overload. Moderate cardiomegaly and tortuous\n aorta are unchanged. The cardiomediastinal silhouette and hilar contours are\n otherwise normal. There is no pleural effusion. Lungs are clear. Right PICC\n line ends in mid-to-lower SVC.\n\n IMPRESSION: No fluid overload. Moderate cardiomegaly unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-08-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1028441, "text": ", J. MED FA5 11:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for fluid overload\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with hyponatremia aggressively fluid replaced with wheezing\n and DOE who does not appear clincally fluid overloaded but want to r/o overload\n radiographically.\n REASON FOR THIS EXAMINATION:\n please assess for fluid overload\n ______________________________________________________________________________\n PFI REPORT\n PFI: Since , there is no volume overload. Moderate cardiomegaly is\n unchanged. Right PICC ends in mid-to-lower SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-08-08 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1028522, "text": " 6:36 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: ERYTHEMA PLEASE ASSESS FOR PRESENCE OF CLOT IN R ARM\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman HTN, CHF, AF, EtOH abuse with PICC line catheter in R arm\n (placed on ) now with erythema, increase in temperature in the right\n arm.\n REASON FOR THIS EXAMINATION:\n Please assess for presence of clot in R arm.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc TUE 1:55 AM\n 1. PICC line visualized within the cephalic vein, without clear flow seen\n around it. A thrombus within the cephalic vein cannot be excluded. The\n remainder of the venous structures of the right upper extremity are normal,\n without evidence of DVT.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old female, with PICC line catheter in the right arm, now\n with erythema and increased temperature of the right arm. Assess for clot.\n\n No prior studies available for comparison.\n\n FINDINGS: Grayscale and color Doppler son of the right internal jugular,\n subclavian, basilic, brachials, axillary, and cephalic veins were obtained.\n There is a PICC line coursing through the cephalic vein. No clear flow is\n seen around the cephalic vein. Evaluation for compression is limited due to\n the presence of the PICC line and a thrombus here cannot be excluded.\n Additionally, there is incomplete compression of the right internal jugular\n vein despite normal color flow demonstrated. The remainder of the venous\n structures demonstrate normal compression, flow, and Doppler waveforms. Color\n Doppler images of the left subclavian vein were obtained for comparison is\n unremarkable.\n\n IMPRESSION:\n 1. PICC line visualized within the cephalic vein without definite flow seen\n in the cephalic vein, and a thrombus cannot be excluded.\n 2. Color flow demonstrated within the internal jugular vein; however, there\n is incomplete compression. This is suggestive of a non occlusive thrombus and\n a follow- up study is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2107-08-08 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1028523, "text": ", J. MED FA5 6:36 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: ERYTHEMA PLEASE ASSESS FOR PRESENCE OF CLOT IN R ARM\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman HTN, CHF, AF, EtOH abuse with PICC line catheter in R arm\n (placed on ) now with erythema, increase in temperature in the right\n arm.\n REASON FOR THIS EXAMINATION:\n Please assess for presence of clot in R arm.\n ______________________________________________________________________________\n PFI REPORT\n 1. PICC line visualized within the cephalic vein, without clear flow seen\n around it. A thrombus within the cephalic vein cannot be excluded. The\n remainder of the venous structures of the right upper extremity are normal,\n without evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2107-08-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1027891, "text": " 9:19 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 49cm right picc. tip?\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with\n REASON FOR THIS EXAMINATION:\n 49cm right picc. tip?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf FRI 11:08 AM\n PICC ends in the proximal right atrium, recommend retraction by 3 cm for a tip\n location in the distal SVC.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 62-year-old woman with right PICC placement.\n\n COMPARISON: at 1:34 a.m.\n\n FINDINGS: Right PICC has been placed, with its tip seen in the proximal right\n atrium. The appearance of the chest is otherwise unchanged from the recent\n prior study, with moderate cardiomegaly and tortuous aorta, without evidence\n of pulmonary edema, effusion, focal consolidation or pneumothorax.\n\n IMPRESSION: Right PICC in the proximal right atrium, it should be retracted\n approximately 3 cm for more optimal tip location in the distal SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-08-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1027892, "text": ", C. MED MICU-7 9:19 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 49cm right picc. tip?\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with\n REASON FOR THIS EXAMINATION:\n 49cm right picc. tip?\n ______________________________________________________________________________\n PFI REPORT\n PICC ends in the proximal right atrium, recommend retraction by 3 cm for a tip\n location in the distal SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-08-09 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1028642, "text": ", J. MED FA5 11:17 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: SWELLING, PLEASE EVAL FOR DVT\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with hyponatremia and new lower extremity edema left worse\n than right.\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT in either lower extremity.\n\n" }, { "category": "Radiology", "chartdate": "2107-08-09 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1028641, "text": " 11:17 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: SWELLING, PLEASE EVAL FOR DVT\n Admitting Diagnosis: HYPONATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with hyponatremia and new lower extremity edema left worse\n than right.\n REASON FOR THIS EXAMINATION:\n please eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KKXa TUE 12:53 PM\n No evidence of DVT in either lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hyponatremia and new lower extremity edema, left worse than\n right.\n\n There are no prior studies for comparison.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: -scale and Doppler son of\n the right and left common femoral, superficial femoral, and popliteal veins\n was performed. Normal flow, augmentation, compressibility and waveforms are\n demonstrated. No intraluminal thrombus is identified. There is moderate\n subcutaneous edema in both calves as described in the history.\n\n IMPRESSION: No evidence of DVT in either lower extremity.\n\n" }, { "category": "ECG", "chartdate": "2107-08-07 00:00:00.000", "description": "Report", "row_id": 117211, "text": "Atrial fibrillation with controlled ventricular response. Low precordial lead\nvoltage. Compared to the previous tracing of the ventricular response\nis increased. Otherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2107-08-05 00:00:00.000", "description": "Report", "row_id": 117212, "text": "Baseline artifact. Atrial fibrillation with slow ventricular response.\nRight bundle-branch block. Q-T interval prolongation. ST-T wave\nabnormalities. Since the previous tracing of the rate has decreased.\nThe right bundle-branch block pattern and Q-T interval prolongation are\nnew. ST-T wave abnormalities are more prominent. Clinical correlation is\nsuggested.\n\n" }, { "category": "Physician ", "chartdate": "2107-08-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 334973, "text": "Chief Complaint: Fatigue/malaise\n HPI: Mrs. is a 62yo woman with a history of --- -who presented\n with fatigue/malaise. The patient reports being in her usual state of\n health until about 5 days ago, when she began feeling extremely\n fatigued & tired. She reports a constellation of associated symptoms,\n including frontal HA, b/l leg discomfort, nausea w/ occasional\n post-prandial emesis, and ? increased LE swelling. She notes that\n prior to these symptoms she was exposed to her , who have had\n a viral-like illness. Over the last few days she notes decreased\n appetite & PO intake. She was at the beach on the day of presentation\n & took in minimal PO. She denies ETOH.\n In the ED,\n Allergies:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\nOther medications: ALBUTEROL - 90 mcg Aerosol - 2 puffs po four times a day as\nneeded\nATENOLOL - 50 mg Tablet - 2 Tablet(s) by mouth once a day\nEPIPEN - 0.3MG Pen Injector - FOR ALLERGIC EMERGENCY\nFEXOFENADINE - 180 mg Tablet - 1 Tablet(s) by mouth once a day\nFOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily\nFUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a\nHYDROCHLOROTHIAZIDE - 25 mg Tablet - one Tablet(s) by mouth once\na day\nLORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day prn\nanxiety\nMETRONIDAZOLE - 0.75 % Cream - apply to affected areas of face\ntwice a day generic is ok\nMETRONIDAZOLE [METROGEL] - 1 % Gel - apply to affected areas once\na day\nNEOMYCIN-POLYMYXIN-HC - 3.5 mg/mL-10,000 unit/mL-1 % Drops,\nSuspension - 2 gtt in each ear four times a day\nMedications - OTC\nCALTRATE PLUS - Tablet - ONE EVERY DAY\nLORATADINE - 10MG Tablet - ONE TABLET BY MOUTH EVERY DAY AS\nNEEDED\nMAGNESIUM - 84MG Tablet Sustained Release - ONE EVERY DAY\nMICONAZOLE NITRATE - 2 % Cream - apply moderate amount ot\naffected areas twice a day\n Past medical history:\n Family history:\n Social History:\n1)Ulcerative Colitis\n on Asacol\n2)Prior Alcohol abuse/use - chronic AST elevation - no history of withdrawal\n3)Hypertension - controlled with Atenolol/hctz\n4)Hypercholesterolemia - last LDL 104\n5)CHF, EF<50% hospitalized in \nModerate MR; Moderate TR; Mild PA HTN.\n6)Multiple environmental allergies\n7)s/p back surgery\n 8) s/p ventral hernia repair\n 9)Anemia\nFamily history is positive for breast cancer in her mother. She\nhas no known history in the family premature CAD.\nMarried with restraining order from abusive husband, 4 children\nand 17 grandchildren. She is close with her children &\nGC. Used to work as a teacher. Denies smoking or\nillicit drug use. Chronic abuse of alcohol, but has been clean for at least 1mo.\nReview of systems: No fevers/chills. No wt change. +LE swelling. B/l leg pain\nfrom thighs to feet asst\nd with a feeling of \"restlessness\" in her legs at HS. +\n nasal congestion, bil ear ache, sore throat. Not sleeping well. + orthopnea at\nbaseline. Possible sick contact w/ her about 1wk ago (they had ?viral\nillness).\n Flowsheet Data as of 06:29 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 63 (62 - 63) bpm\n BP: 125/66(78) {125/66(78) - 125/66(78)} mmHg\n RR: 19 (15 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 1,100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,100 mL\n Respiratory\n SpO2: 95%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 2.0 mEq/L\n [image002.jpg]\n Assessment and Plan\n # Hyponatremia: Last Na in OMR is from & was in 130s. Suspect\n current change is more acute process than chronic, although it is\n difficult to certain of this given that it has been about 1yr since Na\n has been checked. There are likely a few causes of her hyponatremia:\n 1. True volume depletion in setting of decreased fluid intake over last\n ~4days, particularly day of admission when pt was at beach; 2. Thiazide\n diuretics; and 3. Possible SIADH if pt had recent viral infx (may have\n had sick contact w/ ). Pt does have a h/o CHF & c/o of SOB;\n however, her exam is not c/w volume overloaded state. Thus, her\n hyponatremia is likely of the hypovolemic variety. Pt's sx's are\n fatigue, malaise, and nausea. She was started on NS in the ED at a\n rate of 100cc/hr. To get 0.5meq/hr change in Na, the patient will\n likely require ~400cc/hr of NS or about 40-50cc/hr of hypertonic saline\n (based on MedCalc website calculation using Adrogue Formula).\n - Recheck lytes & adjust IVF based on results. Pt may need CVLand\n hypertonic saline if inadequate change in Na w/ NS.\n - Q4h Na checks\n #Hypokalemia:Profoundly low--2. Likely related to thiazide use &\n dehydration. Pt given 60meq of K in ED and has 40meQ in NS IVF.\n - Give addn'l PO K; unable to give addn'l IV K at present as only one\n PIV (failed attempts to get a 2nd)\n #CHF: appears to be hypovolemic at present\n - hold lasix, HCTZ, atenolol\n #Colitis:\n - Con't home meds\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2107-08-05 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 334976, "text": "Chief Complaint: profound hyponatremia and hypokalemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 yr old woman with CHF, colitis, presents to PCP yesterday with\n fatigue and malaise. Labs sent and Na 116 and K 2.0.\n Had been in USOH until 5 days ago, weakess nausea headaches and bilat\n leg pains. + emesis after eating, decrased po intake but kept taking\n lasix and HCTZ. + Exposure to sick contacts with grandchildren having\n viral illness past week.\n IN ED hemodynamics were stable. Rx with NS approx 1L. 100 Kcl po and IV\n Mg 1.1 Ca .3\n Home Meds: Atenalol, Lasix 40, HCTZ 25,\n Allergies:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n systolic CHF - LVEF 50%\n Colitis - on Asachol\n Hx of heavy ETOH use\n Back surgery\n Hernia Repair\n Chronic Anemia\n Breast Cancer\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: Joint pain, Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Heme / Lymph: Anemia\n Neurologic: Headache\n Signs or concerns for abuse\n Flowsheet Data as of 09:00 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 57 (57 - 77) bpm\n BP: 102/27(46) {102/27(46) - 128/66(78)} mmHg\n RR: 11 (11 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 63 Inch\n Total In:\n 2,040 mL\n PO:\n TF:\n IVF:\n 1,040 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,840 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (S1: Normal, No(t) Absent), (S2: Normal, No(t) Distant,\n No(t) Loud, No(t) Widely split , No(t) Fixed), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : )\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): sel, hospital , Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 189 K/uL\n 35.1 %\n 12.5 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 21 mg/dL\n 26 mEq/L\n 73 mEq/L\n 3.1 mEq/L\n 115 mEq/L\n 5.4 K/uL\n [image002.jpg]\n 05:25 AM\n WBC\n 5.4\n Hct\n 35.1\n Plt\n 189\n Cr\n 1.1\n Glucose\n 95\n Other labs: PT / PTT / INR:13.7/29.6/1.2, Differential-Neuts:68.7 %,\n Lymph:15.6 %, Mono:10.1 %, Eos:5.5 %, Ca++:10.3 mg/dL, Mg++:1.1 mg/dL,\n PO4:2.8 mg/dL\n Fluid analysis / Other labs: VITALS:\n No orthostatic changes\n Imaging: CXR : underpenetrated AP:\n no acute infiltrate\n ECG: sinus brady at 55, normal axis, inverted t wave in V1, biphasic in\n V2\n Assessment and Plan\n 62 yr old woman presents with 5 days of weakness and profound\n hyponatremia, hypokalemia, hypomagnesemia\n DDx of this combination of these electrolytes abnormalities likely due\n to hypovolemia, compunded by persistent use of diuretics, and possible\n ETOH use.\n In terms of Na managent: still need to check urine Na (though on lasix)\n and urine Osm - to correct her by 0.5 Meq per hour - we could use 3%\n NaCl versus NaCl - suspect NaCl allone plus stopping the diuretics will\n be enough to get her into the 120 range. needs q2 Na checks, watch\n volume status closely with hydration, 3% if any acute MS changes or\n seizures.\n Needs acute repletion of K and Mg to correct other deficits.\n Calcium - free low but serum high (awaiting albumin) - will repeat\n Check ETOH level and LFTs\n Clarify domestic violence situation\n Access: cuirrently PICC team at bedside, if unable will place CVL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 05:00 AM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2107-08-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 334990, "text": "Chief Complaint: Fatigue/malaise\n HPI: Mrs. is a 62yo woman with a history of --- -who presented\n with fatigue/malaise. The patient reports being in her usual state of\n health until about 5 days ago, when she began feeling extremely\n fatigued & tired. She reports a constellation of associated symptoms,\n including frontal HA, b/l leg discomfort, nausea w/ occasional\n post-prandial emesis, and ? increased LE swelling. She notes that\n prior to these symptoms she was exposed to her , who have had\n a viral-like illness. Over the last few days she notes decreased\n appetite & PO intake. During this period, she has continued on her\n lasix & HCTZ. She denies recent ETOH.\n In the ED, VSS. MS reportedly clear. No sz. Na 116 & K 2.0. Pt\n started on normal saline 100cc/hr w/ KCL. She was also given 60meq KCL\n PO. She is being admitted to the MICU for treatment of her electrolyte\n abnormalities.\n Allergies:\n Lisinopril Rash; Kefzol (Intraven.) (Cefazolin Sodium) Hives;\nOther medications:\nALBUTEROL - 2 puffs po 4xday as needed\nATENOLOL - 100 mg day\nFEXOFENADINE - 180 mg once a day\nFOLIC ACID - 1 mg daily\nFUROSEMIDE 40 mg once a day\nHCTZ - 25 mg once a day\nLORAZEPAM - 0.5 mg twice a day prn Anxiety (unclear if taking)\nMETRONIDAZOLE - 0.75 % Cream - apply to affected areas of face\ntwice a day\nNEOMYCIN-POLYMYXIN-HC - 3.5 mg/mL-10,000 unit/mL-1 % Drops,Suspension - 2 gtt in\n each ear four times a day\nCALTRATE PLUS - ONE EVERY DAY\nLORATADINE - 10MG EVERY DAY\nMAGNESIUM - 84MG SR- EVERY DAY\nMICONAZOLE NITRATE - 2 % Cream - apply moderate amount to affected areas twice a\n day\n Past medical history:\n Family history:\n Social History:\n1)Ulcerative Colitis\n on Asacol\n2)Prior Alcohol abuse/use - chronic AST elevation - no history of withdrawal\n3)Hypertension - controlled with Atenolol/hctz\n4)Hypercholesterolemia - last LDL 104\n5)CHF, EF<50% hospitalized in \nModerate MR; Moderate TR; Mild PA HTN.\n6)Multiple environmental allergies\n7)s/p back surgery\n 8) s/p ventral hernia repair\n 9)Anemia\nFamily history is positive for breast cancer in her mother. She\nhas no known history in the family premature CAD.\nMarried with restraining order from abusive husband, 4 children\nand 17 grandchildren. She is close with her children &\nGC. Used to work as a teacher. Denies smoking or\nillicit drug use. Chronic abuse of alcohol, but has been clean for at least 1mo.\nReview of systems: No fevers/chills. No wt change. +LE swelling. B/l leg pain\nfrom thighs to feet asst\nd with a feeling of \"restlessness\" in her legs at HS. +\n nasal congestion, bil ear ache, sore throat. Not sleeping well. + orthopnea at\nbaseline. Possible sick contact w/ her about 1wk ago (they had ?viral\nillness).\n Flowsheet Data as of 06:29 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 63 (62 - 63) bpm\n BP: 125/66(78) {125/66(78) - 125/66(78)} mmHg\n RR: 19 (15 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 1,100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,100 mL\n Respiratory\n SpO2: 95%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 2.0 mEq/L\n [image002.jpg]\n Assessment and Plan\n 62yo woman w/ h/o HTN & CHF, h/o ETOH abuse (although she denies active\n use), who presents with fatigue, malaise, nausea, and is found to have\n multiple severe electrolyte abnormalities\nhyponatermia, hypokalemia,\n hypomagnesemia.\n # Hyponatremia: Last Na in OMR is from & was in 130s. Suspect\n current change is more acute on chronic process given pt\ns symptoms are\n minimal. There are a few likely causes of her hyponatremia: 1. True\n volume depletion in setting of decreased fluid intake over last ~4days,\n particularly day of admission when pt was at beach; 2. Thiazide\n diuretics; and 3. Possible SIADH if pt had recent viral infx (may have\n had sick contact w/ ). Pt does have a h/o CHF & c/o of SOB;\n however, her exam is not c/w volume overloaded state. She is not\n orthostatic at present, suggesting that she is not profoundly\n hypovolemic either. Given constellation of electrolyte abnormalities,\n suspicion of continued ETOH is present; however, pt reports abstinence\n and ETOH level is negative (>12hr after presentation). Since being\n started on NS in the ED at a rate of 100cc/hr she\ns gotten approx ~1L\n and her Na has not changed, in fact, it has dropped by 1meq. Pt has\n not been able to produce a clean urine sample (ie, not contaminated w/\n large am\nt of stool) & thus Urine Osm not yet sent.\n - Recheck lytes & adjust tx based on results. Get PICC for addn\n access\n - Q2h Na checks\n #Hypokalemia/Hypomag:Profoundly low--2. Likely related to thiazide use\n & dehydration. (As above, still some question of recent ETOH hx). Pt\n given 60meq of K in ED and has 40meQ in NS IVF.\n - Replete K aggressively along w/ magnesium\n # H/o ETOH abuse: pt reports abstinence for >mo. Will start empiric\n CIWA scale in case story not accurate.\n #CHF: appears to be euvolemic to hypovolemic at present\n - hold lasix, HCTZ, atenolol\n #Colitis:\n - Con't home meds\n ICU Care\n Nutrition:\n Lines:\n 20 Gauge - 05:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Communication:\n Code status: Full code\n Disposition: ICU until electrolyte issues stabilized\n" }, { "category": "Physician ", "chartdate": "2107-08-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 334960, "text": "Chief Complaint: Fatigue/malaise\n HPI:\n Allergies:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\nOther medications: ALBUTEROL - 90 mcg Aerosol - 2 puffs po four times a day as\nneeded\nATENOLOL - 50 mg Tablet - 2 Tablet(s) by mouth once a day\nEPIPEN - 0.3MG Pen Injector - FOR ALLERGIC EMERGENCY\nFEXOFENADINE - 180 mg Tablet - 1 Tablet(s) by mouth once a day\nFOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily\nFUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a\nHYDROCHLOROTHIAZIDE - 25 mg Tablet - one Tablet(s) by mouth once\na day\nLORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day prn\nanxiety\nMETRONIDAZOLE - 0.75 % Cream - apply to affected areas of face\ntwice a day generic is ok\nMETRONIDAZOLE [METROGEL] - 1 % Gel - apply to affected areas once\na day\nNEOMYCIN-POLYMYXIN-HC - 3.5 mg/mL-10,000 unit/mL-1 % Drops,\nSuspension - 2 gtt in each ear four times a day\nMedications - OTC\nCALTRATE PLUS - Tablet - ONE EVERY DAY\nLORATADINE - 10MG Tablet - ONE TABLET BY MOUTH EVERY DAY AS\nNEEDED\nMAGNESIUM - 84MG Tablet Sustained Release - ONE EVERY DAY\nMICONAZOLE NITRATE - 2 % Cream - apply moderate amount ot\naffected areas twice a day\n Past medical history:\n Family history:\n Social History:\n1)Ulcerative Colitis\n on Asacol\n2)Prior Alcohol abuse/use - chronic AST elevation - no history of withdrawal\n3)Hypertension - controlled with Atenolol/hctz\n4)Hypercholesterolemia - last LDL 104\n5)CHF, EF<50% hospitalized in \nModerate MR; Moderate TR; Mild PA HTN.\n6)Multiple environmental allergies\n7)s/p back surgery\n 8) s/p ventral hernia repair\n 9)Anemia\nFamily history is positive for breast cancer in her mother. She\nhas no known history in the family premature CAD.\nMarried with restraining order from abusive husband, 4 children\nand 17 grandchildren. She is close with her children &\nGC. Used to work as a teacher. Denies smoking or\nillicit drug use. Chronic abuse of alcohol, but has been clean for at least 1mo.\nReview of systems: No fevers/chills. No wt change. +LE swelling. B/l leg pain\nfrom thighs to feet asst\nd with a feeling of \"restlessness\" in her legs at HS. +\n nasal congestion, bil ear ache, sore throat. Not sleeping well. + orthopnea at\nbaseline. Possible sick contact w/ her about 1wk ago (they had ?viral\nillness).\n Flowsheet Data as of 06:29 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 63 (62 - 63) bpm\n BP: 125/66(78) {125/66(78) - 125/66(78)} mmHg\n RR: 19 (15 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 1,100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,100 mL\n Respiratory\n SpO2: 95%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 2.0 mEq/L\n [image002.jpg]\n Assessment and Plan\n # Hyponatremia: Last Na in OMR is from & was in 130s. Suspect\n current change is more acute process than chronic, although it is\n difficult to certain of this given that it has been about 1yr since Na\n has been checked. There are likely a few causes of her hyponatremia:\n 1. True volume depletion in setting of decreased fluid intake over last\n ~4days, particularly day of admission when pt was at beach; 2. Thiazide\n diuretics; and 3. Possible SIADH if pt had recent viral infx (may have\n had sick contact w/ ). Pt does have a h/o CHF & c/o of SOB;\n however, her exam is not c/w volume overloaded state. Thus, her\n hyponatremia is likely of the hypovolemic variety. Pt's sx's are\n fatigue, malaise, and nausea. She was started on NS in the ED at a\n rate of 100cc/hr. To get 0.5meq/hr change in Na, the patient will\n likely require ~400cc/hr of NS or about 40-50cc/hr of hypertonic saline\n (based on MedCalc website calculation using Adrogue Formula).\n - Recheck lytes & adjust IVF based on results. Pt may need CVLand\n hypertonic saline if inadequate change in Na w/ NS.\n - Q4h Na checks\n #Hypokalemia:Profoundly low--2. Likely related to thiazide use &\n dehydration. Pt given 60meq of K in ED and has 40meQ in NS IVF.\n - Give addn'l PO K; unable to give addn'l IV K at present as only one\n PIV (failed attempts to get a 2nd)\n #CHF: appears to be hypovolemic at present\n - hold lasix, HCTZ, atenolol\n #Colitis:\n - Con't home meds\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2107-08-05 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 335049, "text": "Chief Complaint: profound hyponatremia and hypokalemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 yr old woman with CHF, colitis, presents to PCP yesterday with\n fatigue and malaise. Labs sent and Na 116 and K 2.0.\n Had been in USOH until 5 days ago, weakess nausea headaches and bilat\n leg pains. + emesis after eating, decrased po intake but kept taking\n lasix and HCTZ. + Exposure to sick contacts with grandchildren having\n viral illness past week.\n IN ED hemodynamics were stable. Rx with NS approx 1L. 100 Kcl po and IV\n Mg 1.1 Ca .3\n Home Meds: Atenalol, Lasix 40, HCTZ 25,\n Allergies:\n Lisinopril\n Rash; Abdominal\n Kefzol (Intraven.) (Cefazolin Sodium)\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n systolic CHF - LVEF 50%\n Colitis - on Asachol\n Hx of heavy ETOH use\n Back surgery\n Hernia Repair\n Chronic Anemia\n Breast Cancer\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: Joint pain, Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Heme / Lymph: Anemia\n Neurologic: Headache\n Signs or concerns for abuse\n Flowsheet Data as of 09:00 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 57 (57 - 77) bpm\n BP: 102/27(46) {102/27(46) - 128/66(78)} mmHg\n RR: 11 (11 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 63 Inch\n Total In:\n 2,040 mL\n PO:\n TF:\n IVF:\n 1,040 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,840 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (S1: Normal, No(t) Absent), (S2: Normal, No(t) Distant,\n No(t) Loud, No(t) Widely split , No(t) Fixed), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : )\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): sel, hospital , Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 189 K/uL\n 35.1 %\n 12.5 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 21 mg/dL\n 26 mEq/L\n 73 mEq/L\n 3.1 mEq/L\n 115 mEq/L\n 5.4 K/uL\n [image002.jpg]\n 05:25 AM\n WBC\n 5.4\n Hct\n 35.1\n Plt\n 189\n Cr\n 1.1\n Glucose\n 95\n Other labs: PT / PTT / INR:13.7/29.6/1.2, Differential-Neuts:68.7 %,\n Lymph:15.6 %, Mono:10.1 %, Eos:5.5 %, Ca++:10.3 mg/dL, Mg++:1.1 mg/dL,\n PO4:2.8 mg/dL\n Fluid analysis / Other labs: VITALS:\n No orthostatic changes\n Imaging: CXR : underpenetrated AP:\n no acute infiltrate\n ECG: sinus brady at 55, normal axis, inverted t wave in V1, biphasic in\n V2\n Assessment and Plan\n 62 yr old woman presents with 5 days of weakness and profound\n hyponatremia, hypokalemia, hypomagnesemia\n DDx of this combination of these electrolytes abnormalities likely due\n to hypovolemia, compunded by persistent use of diuretics, and possible\n ETOH use.\n In terms of Na managment: still need to check urine Na (though on\n lasix) and urine Osm - to correct her by 0.5 Meq per hour - we could\n use 3% NaCl versus NaCl - suspect NaCl allone plus stopping the\n diuretics will be enough to get her into the 120 range. needs q2 Na\n checks, watch volume status closely with hydration, 3% if any acute MS\n changes or seizures.\n Needs acute repletion of K and Mg to correct other deficits.\n Calcium - free low but serum high (awaiting albumin) - will repeat\n Check ETOH level and LFTs\n Clarify domestic violence situation\n Access: currrently PICC team at bedside, if unable will place CVL\n ICU Care\n Nutrition: free water restrict until data returns\n Glycemic Control: prn\n Lines / Intubation:\n 20 Gauge - 05:00 AM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n \\:\n Communication: with pt and son\n status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2107-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 335116, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management.\n Electrolyte & fluid disorder (hyponatremia, hypomagnesemia, hypokalemia\n ) related to poor oral intake / lHCTZ.\n Assessment:\n Hyponatremia, hypomagnesemia, hypokalemia as evidenced from lab\n results. Patient alert, oriented X3. EKG sinus brady at times with\n rare PVC\ns noted. Na 117, K : 2.6, Mg : 1.1\n Action:\n Nacl 500 ml fluid bolus given X1. Na Cl with 40 meq KCL started @\n 160 ml /hr for 2 L. 40 meq KCL IV repleted. 6 gm Mg replaced IV. Urine\n sent for osmolality & Na . ( straight cath done to obtain sample).\n Response:\n Patient remains alert, oriented X3. Lab sent at 1630 hrs, waiting for\n result.\n Plan:\n Will closely monitor her electrolye closely. Continue monitoring her\n EKG & mental status.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Remains with the patient. Encouraged the patient to use call light for\n assistance.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercize.\n Plan:\n Cont to monitor her sats closely. If needed may start O2 per NC.\n" }, { "category": "Nursing", "chartdate": "2107-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 335119, "text": "TITLE: 62 yr old woman with CHF, colitis, presents to PCP yesterday\n with fatigue and malaise. Labs sent and Na 116 and K 2.0. Had been in\n USOH until 5 days ago, weakess nausea headaches and bilat leg pains. +\n emesis after eating, decrased po intake but kept taking lasix and\n HCTZ. Exposure to sick contacts with grandchildren having viral\n illness past week. at 0400 hrs presented to :ED with\n electrolye imbalances. Hemodynamically stable. Rx with NS approx\n 1L. Tranx to MICU for further management.\n Electrolyte & fluid disorder (hyponatremia, hypomagnesemia, hypokalemia\n ) related to poor oral intake / lHCTZ.\n Assessment:\n Hyponatremia, hypomagnesemia, hypokalemia as evidenced from lab\n results. Patient alert, oriented X3. EKG sinus brady at times with\n rare PVC\ns noted. Na 117, K : 2.6, Mg : 1.1\n Action:\n Nacl 500 ml fluid bolus given X1. Na Cl with 40 meq KCL started @\n 160 ml /hr for 2 L. 40 meq KCL IV repleted. 6 gm Mg replaced IV. Urine\n sent for osmolality & Na . ( straight cath done to obtain sample).\n Response:\n Patient remains alert, oriented X3. Lab sent at 1630 hrs, waiting for\n result.\n Plan:\n Will closely monitor her electrolye closely. Continue monitoring her\n EKG & mental status.\n Activity Intolerance, fatigue related to CHF\n Assessment:\n SOB noted when patient OOB (using Commode). Maintained sats at low\n 90\ns. C/O tiredness. Sats at 100% while at rest.\n Action:\n Remains with the patient. Encouraged the patient to use call light for\n assistance.\n Response:\n With one assistance patient does ok.. Continuing deep breathing &\n coughing exercize.\n Plan:\n Cont to monitor her sats closely. If needed may start O2 per NC.\n" } ]

[ { "category": "Radiology", "chartdate": "2103-01-11 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 775697, "text": " 11:59 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: Evaluate for aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with copd exacerbation, s/p seizure\n REASON FOR THIS EXAMINATION:\n Evaluate for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 88 y/o with COPD exacerbation and a seizure who is s/p extubation.\n\n TECHNIQUE: The study was performed in conjunction with the speech therapist.\n Various consistencies of barium were administered orally.\n\n FINDINGS: There was premature spillage of thin, however, there was no\n significant amount of residue seen in the vallecula and piriform sinuses.\n There was good laryngeal elevation. However, there was penetration with thins\n and thicks. There is also minimal aspiration seen with thin liquids with the\n straw sip. There is no spontaneous cough. On swallowing pill, the pill was\n hung up in the lower esophagus. There is also incidentally noted a prominent\n upper esophageal sphincter, however, this did not impede swallowing.\n\n IMPRESSION: Penetration with minimal amount of aspiration. Please see the\n speech and swallowing report for detailed description and the findings and for\n recommendations.\n\n" }, { "category": "Radiology", "chartdate": "2103-01-12 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 775793, "text": " 10:50 AM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: HX COPD/BULLOUS CHANGES, S/P SZ,SIADH, EVAL FOR LUNG MASS, EMPHYSEMA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with COPD/bullous changes, s/p sz, siadh.\n REASON FOR THIS EXAMINATION:\n Please include high res CT: Evaluate for lung mass, emphysema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n History of SIADH and emphysema.\n\n Multiple axial images of the chest were obtained after the adminsistration of\n intravenous contrast.\n\n CONTRAST: 100 cc of Optiray were administered due to the patient's underlying\n COPD. There were no complications. Additionally, high resolution images of\n the lungs were obtained.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: Diffuse, severe emphysema,\n predominantly centrilobular is seen. Several bullae are present within the\n medial right lower lobe. Several calcified lung nodules measuring less then\n 1 cm are consisent with granulomas. There is a small left pleural effusion.\n There is also a tiny white pleural effusion. A non-calcified 3 mm nodule is\n present within the left upper lobe. Within the right upper lobe, is a 7 by 8\n mm non-calcified nodular density with somewhat spiculated margins, adjacent to\n the major fissure. Within the right hilum, is a soft tissue density measuring\n approximately 2.5 by 1.3 cm. Adjacent to the left effusion, is an area of\n focal consolidation. Within the opacified pulmonary vessels, in this region,\n there are apparent subtle filling defects.\n\n A tiny low attenuation lesion within segment 4 of the liver is too small to\n fully characterized. A tiny low attenuation lesion within the mid right kidney\n may represent a simple cyst. The remaining superior portions of the kidneys,\n pancrease and spleen are normal in appearance. There is a small hiatal hernia.\n\n Bone windows. No destructive lesions are identified.\n\n IMPRESSION:\n 1. Severe underlying diffuse centrilobular emphysema.\n 2. Several abnormalities strongly concerning for primary lung cancer,\n including an area of consolidation within the left lower lobe with a\n suggestion of emboli within the adjacent lower lobe pulmonary arteries.\n Because of this finding, repeat study according too PE protocol is recommended\n as further evaluation. This finding and the recommendation were discussed\n with Dr. on the day of the study.\n\n There is also a spiculated nodule within the right upper lobe and a 2.5 cm\n soft tissue lesion within the right hilum. These may represent a primary lung\n (Over)\n\n 10:50 AM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: HX COPD/BULLOUS CHANGES, S/P SZ,SIADH, EVAL FOR LUNG MASS, EMPHYSEMA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n neoplasm with adjacent lymph adenopathy, or alternatively, separate\n synchronous lesions.\n\n" }, { "category": "Radiology", "chartdate": "2103-01-05 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 775250, "text": " 8:06 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: DWI for ?seizure\n Contrast: MAGNEVIST Amt: 10CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with ?seizure in setting of COPD exacerbation\n REASON FOR THIS EXAMINATION:\n DWI for ?seizure\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient with question of seizure in the setting of COPD\n exacerbation for further evaluation.\n\n TECHNIQUE: T1 sagittal and axial, and FLAIR, T2 and susceptibility axial\n images were obtained. Diffusion axial images were also acquired. Following\n gadolinium T1 and coronal images were obtained. There are no prior similar\n examinations for comparison. Correlation was made with the head CT of\n .\n\n FINDINGS: There is moderate prominence of ventricles and sulci indicating\n brain atrophy. Moderate periventricular and subcortical white matter\n T2 hyperintense changes are present indicating small vessel disease. On the\n diffusion images no evidence of an area of restricted diffusion is identified\n indicating acute infarct. There is no midline shift mass effect or hydro-\n cephalus is seen. Small chronic lacunes are identified adjacent to the right\n lateral ventricle. Following gadolinium no evidence of abnormal parenchymal\n vascular or meningeal enhancement is identified.\n\n IMPRESSION: Moderate changes of small vessel disease. Brain atrophy. No\n evidence of hydrocephalus or mass effect. No evidence of abnormal enhancement.\n No evidence of acute infarct.\n\n" }, { "category": "Radiology", "chartdate": "2103-01-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 775622, "text": " 4:15 PM\n CHEST (PA & LAT) Clip # \n Reason: EVALUATE FOR atelectasis, infiltrate, fluid, change in CXR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with COPD flare s/p extubation now w/desat and diffuse\n crackles.\n REASON FOR THIS EXAMINATION:\n EVALUATE FOR atelectasis, infiltrate, fluid, change in CXR\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST:\n\n INDICATION: Desaturation and crackles on exam.\n\n COMPARISON: .\n\n FINDINGS: There has been interval removal of the endotracheal tube. Left\n subclavian central venous line remains in good position. The heart is not\n enlarged. The aorta is unfolded. Bilateral pleural effusions have developed,\n left greater than right. There is bibasilar atelectasis. The lungs remain\n hyperexpanded with flattened diaphragms. There is biapical pleural\n thickening.\n\n IMPRESSION: Interval development of bilateral pleural effusions, left greater\n than right.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-01-10 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 775614, "text": " 3:18 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: MS CHANGES, S/P GRAND MAL SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman who presented w/change MS, COPD exacerbation s/p extubation,\n s/p grand mal sz w/resolving residual deficits.\n REASON FOR THIS EXAMINATION:\n Evaluate for stenotic disease.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88 year old woman with change MS, grand mal seizure, and resolving\n residual deficits. Request to evaluate for possible carotid artery stenosis.\n\n TECHNIQUE AND FINDINGS: scale, color doppler and spectral doppler\n examinations were performed at the level of the cervical portions of the\n bilateral carotid and vertebral arteries.\n\n On the right, no significant plaque is seen on real-time ultrasonography. The\n peak systolic velocities (PSVs) in the internal (ICA), common (CCA) and\n external (ECA) carotid arteries are 68, 77 and 87 cm per second respectively.\n The right ICA to CCA PSV ratio is 0.88. There is antegrade flow in the right\n vertebral artery with a PSV of 40 cm per second.\n\n On the left, the PSV in the ICA, CCA and ECA are 105, 80 and 91 cm per second,\n respectively. The left ICA to CCA PSV ratio is 1.31. There is antegrade flow\n in the left vertebral artery with a PSV of 36 cm per second.\n\n IMPRESSION:\n - Absence of significant carotid artery stenosis, with minimal luminal\n narrowing (less than 40 %) in the left ICA and no disease on the right side.\n - Antegrade flow in the bilateral vertebral arteries.\n\n" }, { "category": "Radiology", "chartdate": "2103-01-13 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 775884, "text": " 12:40 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: EVAL FOR THOMBUS, COPD/BULLOUS CHANGES, S/P SZ SIAADH, CONCERNED FOR THROMBUS IN PULMONARY VASCULURE AREA\n Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with COPD/bullous changes, s/p sz, siadh. Chest CT shows\n findings concerning for thrombus in pulm vasculature.\n REASON FOR THIS EXAMINATION:\n Evaluate for thrombus.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath, possible pulmonary embolus seen on recent CT.\n COMPARISON: .\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n thoracic inlet through the lung bases, with the administration of IV contrast.\n Sagittal, coronal and paddle wheel reformatted images were performed.\n\n CT CHEST WITH IV CONTRAST: The lung windows again demonstrate extensive\n emphysematous changes throughout both lungs. There are numerous large bullae\n within subpleural distribution. There are numerous nodules scattered\n throughout both lungs, many of which are coarsely calcified. However, there\n is a nodular density in the right upper lobe anterior to the major fissure and\n in the the extreme right lung apex posteriorly noncalcified. The nodular\n density on (series 2 image 122) is slightly irregular in contour. The airways\n are patent to the level of the segmental bronchi bilaterally. The soft tissue\n windows demonstrate no filling defects within the pulmonary arteries. There\n are several enlarged lymph nodes in the right hilar region, measuring\n approximately 1 cm in diameter. No other significant mediastinal, hilar or\n axillary lymphadenopathy is noted. The heart, pericardium and great vessels\n are unremarkable. There is a small left pleural effusion. There is a small\n region of patchy atelectasis at the left lung base.\n\n The osseous structures are unremarkable.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolus.\n 2. Extensive bullous emphysema.\n 3. Numerous pulmonary nodules many of which are coarsely calcified. The\n calcified nodules are consistent with prior granulomatous infection. However,\n there are at least 2 slightly irregular nodulare densities in the right upper\n lobe. Given the lack of calcification in these regions in combination with\n the right hilar adenopathy it is difficult to entirely exclude a neoplasm.\n 4. Small left pleural efffusion.\n\n" }, { "category": "Radiology", "chartdate": "2103-01-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 775185, "text": " 6:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 88 yo F with COPD, intubated, sedated with recent seizure, e\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with\n REASON FOR THIS EXAMINATION:\n 88 yo F with COPD, intubated, sedated with recent seizure, evaluate for bleed,\n acute process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 88 y/o woman with COPD intubated with recent seizure, evaluate for\n bleed.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast CT of the brain.\n\n FINDINGS: There are no abnormal extra-axial collections, mass effect, shift of\n the normally midline structures. There is no acute intracranial hemorrhage.\n Ventricles and sulci are within normal limits for size. There is an old right\n caudate head lacune. Thre is slightly more prominent cerebral white matter\n patchy hypodensity, probably related to microvascular ischemic gliosis and\n infarction.\n There are no skull fractures seen. The visualized paranasal sinuses are well\n aerated.\n\n IMPRESSION: No acute intracranial hemorrhage or mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2103-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 775230, "text": " 2:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval placement of o-g tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with copd now decreased BP s/p left SC line\n\n REASON FOR THIS EXAMINATION:\n please eval placement of o-g tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: History of COPD with decreasing blood pressure. S/P left\n subclavian line placement. Evaluate placement of orogastric tube.\n\n FINDINGS:\n\n" }, { "category": "Radiology", "chartdate": "2103-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 775174, "text": " 12:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with copd now decreased BP s/p left SC line\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 88 year old with COPD and decreased blood pressure after placing a\n subclavian line.\n\n Comparison is made to a study done a few minutes earlier.\n\n PORTABLE CHEST: The tip of an endotracheal tube is noted to be in the right\n main stem bronchus. It should be pulled back approximately 4 cm. The tip of\n a left subclavian line is seen in the superior vena cava. There are no\n pneumothoraces seen. The cardiac, hilar and mediastinal silhouettes are\n unchanged. There is biapical pleural thickening and hyperinflation of the\n diaphragms.\n\n IMPRESSION:\n 1. No pneumothorax.\n 2. Endotracheal tube in the right main stem bronchus which should be pulled\n back.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 775176, "text": " 1:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: OETT Placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with copd now decreased BP s/p left SC line\n REASON FOR THIS EXAMINATION:\n OETT Placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Central line placement. Check positioning.\n\n COMPARISON: 1.5 hours earlier.\n\n FINDINGS: Endotracheal tube is in good position. A left subclavian central\n venous line is in unchanged position. The lungs are hyperexpanded\n bilaterally, with flattened diaphragms suggestive of emphysema. Cardiac and\n mediastinal contours are normal. There is no pulmonary vascular congestion.\n The soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: Satisfactory placement of tubes and lines. Emphysema.\n\n" }, { "category": "Radiology", "chartdate": "2103-01-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 775172, "text": " 11:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 88 yo female, s/p intubation in field for copd flare assess\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with copd\n REASON FOR THIS EXAMINATION:\n 88 yo female\n s/p intubation in field for copd flare assess placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 88 year old woman with COPD flare.\n\n COMPARISON: .\n\n PORTABLE CHEST: The tip of an endotracheal tube is seen at the level of the\n carina. The tube should be pulled back approximately 4 cm. There is a left\n subclavian line with its tip in the superior vena cava. There is no\n pneumothorax seen. The cardiac, hilar and mediastinal silhouettes are within\n normal limits for size. There is biapical pleural thickening. The lungs are\n hyperinflated. The visualized bones are unremarkable.\n\n IMPRESSION:\n 1. Endotracheal tube in unsatisfactory position and should be pulled back\n approximately 4 cm.\n 2. Hyperinflated lungs.\n 3. No pneumothorax.\n\n\n" }, { "category": "Echo", "chartdate": "2103-01-12 00:00:00.000", "description": "Report", "row_id": 65054, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 115\nBSA (m2): 1.55 m2\nBP (mm Hg): 132/60\nStatus: Inpatient\nDate/Time: at 13:43\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nLeft ventricular systolic function is hyperdynamic (EF>75%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is borderline pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. Left ventricular systolic function is hyperdynamic\n(EF>75%). Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is borderline pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nCompared with the prior study of , there is no significant change\n\n\n" }, { "category": "ECG", "chartdate": "2103-01-05 00:00:00.000", "description": "Report", "row_id": 128081, "text": "Sinus rhythm. Compared to the previous tracing no major change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2103-01-04 00:00:00.000", "description": "Report", "row_id": 128082, "text": "Sinus rhythm. Compared to the previous tracing marked J point elevation and\nearly repolarization persist.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2103-01-04 00:00:00.000", "description": "Report", "row_id": 128083, "text": "Normal sinus rhythm. Delayed anterior precordial R wave progression with marked\nJ point elevation and early repolarization. Compared to the previous tracing\nof no major change.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2103-01-05 00:00:00.000", "description": "Report", "row_id": 1486746, "text": "1743: 7a-7p END OF SHIFT NURSING NOTE\n\npt is full code\nadmitted for copd exacerbations, tubed in field, seizure since admit to unit-postictal\n\nNEURO: pt remains \"sedated\" however on no sedation medication. last dose of ativan 0.5mg given at 1025. no pain meds given. pt had sz at 0450 but no further sz activity. within last hour pt more open with eyes to stimuli. has not followed commands w/ any extremities. perla at 3mm fairly brisk react. withdraws to all extremities...slower to react on rt side. occas spont movements noted w/ bil feet, none in bue.\n\nRESP: w/ 7.0 ett at 21cm lip. have been adjusting settings all day w/ multiple abg's sent. currently on pressure support only w/ rr around 4 and sats 98-100%....intern discussing w/ resident at this time. fio2 0.35 w/ 5peep. lungs essentially clear this shift. occas thick sputum sx. clearish oral secretions sx also.\n\nCARDIAC: nsr rate 70-80s no ectopy noted. rt radial artline w/ pressures 110-150s and nibp 110-140s. no correlating 100%, usually around 20mmhg off w/ art line higher. skin warm and dry...cool lower extremitieds. 1+ pitting bil ankle/foot edema and slight pitting on lower legs. pulses weak but palpable. tmax 100.6 orally, md aware.\n\nGU/GI: abd soft and slightly distended ?pt norm? w/ active bowel sounds. no bm this shift. ogt placed for meds and possible tube feeds. good placement. foley draining clear yellow urine which has been dipping down in last couple hours.\n\nSKIN: intact, bruise to rt shin\n\nACCESS: rt radial artline. lt tlsc all ports flush w/o diffculty.\n\npt wrists remain restrained. plan: to mri tonite....\neeg completed today along w/ neuro consult.\n" }, { "category": "Nursing/other", "chartdate": "2103-01-06 00:00:00.000", "description": "Report", "row_id": 1486747, "text": "7P-7A NURSING NOTE:\nPlease see carevue for objective data:\n\nNeuro: Pt alert at times with agitation and attempts to speak. MAE. R side weaker than L. Intermittently follows commands. Pt to MRI last night with and without contrast to R/O cerebral infarct. No seizure activity. Pt started on PO dilantin.\n\nResp: Pt maintained on mechanical with settings adjusted betw PS/CMV. Pt currently on CMV 10/VT 500/ .35/peep 5. RR 10-16. VT .5-.71. ABG's done, see carevue. LS course, dim bases. SPO2 94-98%.\nPt sxn'd for clear oral secreations/sm amt yellow via ETT.\n\nCV: Tele: NSR without ectopy. HR 70-90's. R ABP 130-160's/50-70's. L SC TLC patent for NS KVO and IV meds.\n\nGI/GU: OGT in place, patent for po meds. Abd soft, +BS. Foley in place draining yellow urine. No BM.\n\nSkin: Intact.\n\nPlan:\nMonitor VS, resp status, support\nMonitor I&O's\nMonitor for seizure activity, MRI results pending\nMonitor pending am labs\nUpdate family on plan of care\n" }, { "category": "Nursing/other", "chartdate": "2103-01-05 00:00:00.000", "description": "Report", "row_id": 1486742, "text": "Respiratory Care:\n\n88 yr old female in the field for Resp failure/Copd Exacerbation. Pt. with 7.0 ETT/taped initally at 22cm. Rx'd with combivent and ventolin in the field. Bs decreased/equal bilaterally. Sx'd for moderate amounts of thick white sputum and thick blood tinged sputum. CXR revealed ETT needed to be pulled back 2cm. ETT pulled back to 20cm. Bs equal bilaterally and coarse bilaterally. Albuterol MDI given x 2 with 10 puffs each rx. Airway pressures improving. settings initially Vt 500, Simv 12, Fio2 50%, Peep 5, Psv 5. PAP decreasing from 38-40's to 30's/plateau pressure 23. Auto peep 5. PaCo2 116. Rate increased to 18, with Vt to 550. Pt. transported to Micu B. Plan to repeat Abg and CXR. Wean rate as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2103-01-05 00:00:00.000", "description": "Report", "row_id": 1486743, "text": "NURSING PROGRESS NOTE 1A-7A\nREPORT RECEIVED FROM EW. PT ARRIVED TO UNIT VIA STRETCHER AND ON CARDIAC MONITOR ACCOMPANIED BY MD . PT TRANSFERRED TO MICU 776 WITH NO UNTOWARD EVENTS. PT'S ENVIRONMENT SECURED FOR SAFETY. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY.\n\nPT IS WELL KNOWN TO MICU STAFF. HAS EXTENSIVE HISTORY OF COPY FLARE UPS REQUIRING INTUBATION. TONIGHT PT WAS EATING DINNER WHEN FAMILY NOTED PT TO BE EXPERIENCING DYSPNEA AND LETHARGY. EMS PT ON THE FIELD AND PRESENTED TO EW. PT HAD ALINE AND TLC TO LEFT CVL INSERTION- WAS GIVEN FENTANYL PRIOR TO THIS, PT THEN EXPERIENCED HYPOTENSIVE CRISIS REQUIRING DOPAMINE DRIP AT 20MCG/KG/MIN AND BOLUS OF 3 LITERS TOTAL. PT STABILIZED AND TRANSPORTED TO UNIT- WEANED OF DOPA SUCCESFULLY PRIOR TO TRANSFER.\n\nNEURO: PT ARRIVED EXTREMELY AGITATED ATTEMPTING TO PULL OUT OETT, RESTRAINTS APPLIED FOR SAFETY PRECAUTIONS. WOULD FOLLOW COMMANDS INTERMITTENTLY. MAE X 4 WITH PURPOSE. EQUAL STRENGTH NOTED TO BILATERAL UPPER AND LOWER EXTREMETIES. INITIAL ASSESSMENT- PERLA. WOULD RESPOND TO PAINFUL AND VERBAL STIMULUS. AT 0450 PT NOTED TO HAVE GRAND MAL SEIZURE WITH COARSE, BUCKING BODY TREMORS, DESATURATION TO THE 60'S, EYES ROLLING TO THE BACK OF THE HEAD. PT HAD PERIOD OF SVT 190'S- NARROW COMPLEX WHICH SHE EVENTUALLY CONVERTED WITHOUT INTERVENTION DURING SEIZURE ACTIVITY. EKG OBTAINED ALTHOUGH PT HAD ALREADY CONVERTED BACK TO NSR. PT GIVEN 2 MG OF ATIVAN IVP WITH GOOD RESULTS. POSTYCTAL NEURO EXAMINATION FINDS THAT PT WILL RESPOND TO PAINFUL STIMULUS AND STILL PERLA. MD IS AWARE. AFEBRILE. TOX SCREEN DRAWN WITH PENDING RESULTS.\n\nRR: PT HAS #7 OETT, SECURE AND PATENT, 20CM TO THE LIP. IMV, 550, 16, 35%, . THIS PT. IS KNOWN TO RETAIN CO2 IN THE 50-60'S. BBS=, BILATERAL UPPER LOBES ARE COARSE, BILATERAL LOWER LOBES ARE NOTED TO BE DIMINISHED. SUCTIONING IS PRODUCTIVE FOR THICK, WHITE SECRETIONS. NO SOB NOTED. REGULAR RHYTHM OF BREATHING. SP02 95% OR GREATER. RR= 16.\n\nCV: NSR ASIDE FROM SEIZURE EPISODE AS DESCRIBED ABOVE. HR 80'S WITH NO SIGNS OF ECTOPY NOTED. SBP HAVE BBEN LABILE 79-130'S, DOPA DRIP RESTARTED AT 0600 TO MAINTAIN MEAN OF 60 AND ABOVE. WILL ATTEMPT TO WEAN OFF AS TOLERATED. S1 AND S2 AS PER AUSCULTATION. PALPABLE BILATERAL RADIAL AND DORSALIS PEDIS. NO SIGNS OF JVD NOTED. A-LINE TO RIGHT RADIAL IS SECURE AND PATENT- RECALIBRATED AND REZEROED DURING THE SHIFT. TLC CVL TO LEFT SCL IS SECURE AND PATENT-FLUSHES AND DRAWS BACK BLOOD WITHOUT DIFFICULTY.\n\nGI: ABDOMEN IS SOFT AND NON-DISTENDED. BS X 4 QUADRANTS. PT IS PASSING POSITIVE FLATUS- NO BM THIS SHIFT.\n\nGU: INDWELLING FOLEY CATHETER- SECURE AND PATENT. ADEQUATE UOP NOTED- YELLOW AND CLEAR.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nELECTROLYTES- TOX SCREEN AND REPEAT SET OF LYTES IS PENDING. PT 2 GMS OF MAG.\n\nPLAN: CONTINUE TO MONITOR SEIZURE ACTIVITY AND TREAT ELECTROLYTES AS NEEDED, WILL GO DOWN TO CT SCAN FOR HEAD SCAN. MONITOR BP. PLE\n" }, { "category": "Nursing/other", "chartdate": "2103-01-05 00:00:00.000", "description": "Report", "row_id": 1486744, "text": "NURSING PROGRESS NOTE 1A-7A\n(Continued)\nASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n" }, { "category": "Nursing/other", "chartdate": "2103-01-05 00:00:00.000", "description": "Report", "row_id": 1486745, "text": "Respiratory Care Note:\n Patient weaned to PSV today with goal to normalize ph. See Carevue flowsheet. BS are equal bilat with improving aeration, scattered rales and rhonchi occassionally. Suctioned for med amounts of tannish blood tinged sputum, becoming clearer this afternoon.\n Patient opens eyes to stimuli, doesn't follow commands. Head CT done this am, EEG this afternoon, plan for MRI this evening. She is not on any sedation. Plan to maintain airway at this time. She is ordered for albuterol and atrovent nebs for hx COPD. She appears comfortable on PSV with alarms set and functional.\n" }, { "category": "Nursing/other", "chartdate": "2103-01-06 00:00:00.000", "description": "Report", "row_id": 1486748, "text": "7a-7p\ncv: hr nsr(76-93), no ectopy, sbp stable (108-149)\n\nresp: pt on AC ventilation this am, weaned to cpap, tol well & pt extubated @ 1030, placed on 40% ofm then changed to 3-4 l np, abg on 3 l np @ 1800 = 7.34/66/71/37/94&, no resp distress noted, rr 23-33, sats 93-98, bs+ all lobes & clear, non productive cough\n\ngi: oral gt dc'd with extubation, sips cl lix given with meds, no stool, no nausea\n\ngu: foley cath patent, uo clear, good uo\n\nneuro: awake, moving all extremities, confused, follows commands @ times, no seizure activity noted, continues on po dilantin\n\nplan: monitor resp status in icu overnoc, tx to floor in am if stable\n" }, { "category": "Nursing/other", "chartdate": "2103-01-06 00:00:00.000", "description": "Report", "row_id": 1486749, "text": "Respiratory Care Note:\n Patient extubated at 10:30 am and has been on 3lpm nasal O2 with adequate (fairly normalized for her COPD status) results. BS equal bilat, diminished and with crackles t/o. HX of emphysema and home O2. Plan to maintain PCO2 in the 50-60 range and use BIPAP prn if her work of breathing becomes more difficult. Respirations have been shallow and rapid at 28-35BPM. Cough moist and non-productive on request. Switched over to med nebs post extubation and tolerates those well with albuterol and atrovent unit dose.\n" }, { "category": "Nursing/other", "chartdate": "2103-01-07 00:00:00.000", "description": "Report", "row_id": 1486750, "text": "Nursing Progress Note\nNeuro: Pt extremely HOH, has no hearing aid with her in hospital, communication difficult at times. MAE, requesting cups of tea, extra blankets overnight.\nResp: Doing well extubated, sats 93% on 3l NP baseline\nCV: Stable, SBP 110-140, tolerating Diltiazem dose.\nGI: Tol clear liquids well. Small soft OB neg stool on bedpan x1.\nGU: Adequate urine output via FC\nSocial: No contact with family members overnight.\n" } ]

[ { "category": "Echo", "chartdate": "2146-06-29 00:00:00.000", "description": "Report", "row_id": 67539, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Endocarditis.\nHeight: (in) 69\nWeight (lb): 180\nBSA (m2): 1.98 m2\nBP (mm Hg): 106/46\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 11:56\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: ?# aortic valve leaflets. Aortic valve not well seen. No masses\nor vegetations on aortic valve, but cannot be fully excluded due to suboptimal\nimage quality. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No masses or\nvegetations on mitral valve, but cannot be fully excluded due to suboptimal\nimage quality. Mild mitral annular calcification. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild PA systolic\nhypertension.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. The number of aortic valve leaflets\ncannot be determined. The aortic valve is not well seen. No masses or\nvegetations are seen on the aortic valve, but cannot be fully excluded due to\nsuboptimal image quality. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. No masses or vegetations are seen on the mitral\nvalve, but cannot be fully excluded due to suboptimal image quality. Trivial\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is mild pulmonary artery systolic hypertension. There is no\npericardial effusion. There is an anterior space which most likely represents\na fat pad.\n\nIMPRESSION: poor technical quality due to patient's body habitus. Left\nventricular function is probably normal, a focal wall motion abnormality\ncannot be fully excluded. The right ventricle is not well seen. No cardiac\nsource of embolism or evidence of endocarditis identified. No significant\nvalvular abnormality seen.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar. A cardiac source of embolus cannot be definitively excluded.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n" }, { "category": "Physician ", "chartdate": "2146-06-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 383826, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 02:00 PM\n - HIDA scan showed acute cholecystitis, not candidate for surgery given\n multiple comorbidities. IR contact for percutaneous cholecystostomy,\n but INR was 5.3, needs to be 1.5\n - gave vitamin K to bring down INR\n - blood culture grew GPC in pairs and clusters x 1, pending speciation\n - given 1 unit FFP for possible line, PICC in the AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin/Tazobactam (Zosyn) - 05:37 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Morphine Sulfate - 03:35 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 74 (74 - 145) bpm\n BP: 111/57(69) {96/43(55) - 133/71(79)} mmHg\n RR: 18 (17 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.6 kg (admission): 82.4 kg\n Total In:\n 5,687 mL\n 458 mL\n PO:\n TF:\n IVF:\n 5,250 mL\n 368 mL\n Blood products:\n 257 mL\n Total out:\n 3,065 mL\n 510 mL\n Urine:\n 2,590 mL\n 510 mL\n NG:\n 475 mL\n Stool:\n Drains:\n Balance:\n 2,622 mL\n -52 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 3L\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n General: eyes open, grimaces to exam, no response to verbal stim\n HEENT: Sclera anicteric, pupils reactive\n Neck: supple, unable to assess JVP\n Lungs: audible upper airway secretions with rhonchi, difficult to\n appreciate any wheezes or rales, dysynchronous abd breathing\n CV: RRR, unable to appreciate murmurs through upper airway sounds\n Abdomen: mildly distended, no bowel sounds audible, grimaces to deep\n palpation, unable to assess rebound/guarding\n GU: foley in place\n Ext: warm, 1+ pulses, no cyanosis or edema, erosion and lateral\n deviation over MTP joint, no erythema or active drainage.\n Labs / Radiology\n 160 K/uL\n 9.5 g/dL\n 123 mg/dL\n 1.5 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 110 mEq/L\n 142 mEq/L\n 28.3 %\n 22.3 K/uL\n [image002.jpg]\n \n 5am.\n 11:42 PM\n 12:31 AM\n 04:49 AM\n 04:28 PM\n 10:53 PM\n 05:04 AM\n WBC\n 28.6\n 26.3\n 25.5\n 22.3\n Hct\n 32.6\n 30.7\n 26.9\n 28.1\n 28.3\n Plt\n 166\n 156\n 155\n 160\n Cr\n 1.9\n 1.7\n 1.6\n 1.5\n TropT\n 0.03\n 0.02\n 0.01\n TCO2\n 21\n Glucose\n 123\n 107\n 128\n 123\n Other labs: PT / PTT / INR:41.1/54.6/4.3, CK / CKMB /\n Troponin-T:400/9/0.01, ALT / AST:24/43, Alk Phos / T Bili:50/0.9,\n Amylase / Lipase:37/11, Differential-Neuts:94.3 %, Lymph:1.3 %,\n Mono:3.2 %, Eos:0.1 %, D-dimer:962 ng/mL, Fibrinogen:736 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:2.6 g/dL, LDH:177 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.1 mg/dL\n .\n HIDA : Acute Cholecystitis\n .\n CXR :\n .\n C. diff negative x2\n .\n MRSA\n pending\n .\n BCx \n gram + cocci in pairs and clusters (anaerobic bottle)\n BCx - NGTD\n .\n UCx- NGTD\n Assessment and Plan\n 83 y/o M with PMhx of CVA, Recurrent Aspiration and UTIs who presented\n with fever, tachypnea and suspected aspiration now with CT abd\n concerning for cholecystitis.\n .\n # Fever/Leukocytosis: Etiology unclear and multiple possible sources,\n loose stools and impressive leukocytosis makes Cdiff a possible source,\n h/o recurrent aspiration PNA with infiltrates and hypoxia suggests a\n possible component of aspiration PNA or pneumonitis. Initial UA\n positive for UTI and currently awaiting culture data. Additional\n concern for cholecystitis although Tbili only mildly elevated and alk\n phos was normal.\n - f/u urine, blood, sputum Cx if possible\n - continue empiric Vanc/Zosyn, Flagyl\n - send stool for Cdiff\n - repeat CXR in am\n - bolus IVF prn\n - goal UOP>30cc/hr\n - f/ recs, consider MRCP in am\n - f/u final read on CT abd and RUQ u/s\n - trend lactate, CBC, LFTs\n - aggressive pulm toilet\n - t/b with family regarding goals\n .\n # Hypoxia: Pt with h/o recurrent aspiration, now with possible right\n lower lobe infiltrate and bilateral lower lobe consolidation on CT abd\n (lung cuts). Pt unable to give h/o cough but with large A-A gradient\n and diffuse audible secretions. Possible additional component of pulm\n edema though pt is likely unable to clear secretions and protect\n airway. Possible aspiration in the NH prior to transfer to ED.\n - cover empirically with Vanc/Zosyn\n - send urine/blood and sputum Cx if possible\n - albuterol/atrovent nebs\n - attempt pulm toilet\n - hold off on diuresis given recent hypotension\n - f/u CXR in am\n .\n # ARF: Pt with acute renal failure likely due to dehydration and\n hypoperfusion. Pt may have component of ATN given hypotension though\n making good urine and creatinine trending down with IVF, will continue\n to trend UOP with boluses. Pt with h/o recurrent UTI and stones though\n no clear evidence of obstruction of CT abd\n - bolus IVF\n - goal UOP of >30cc/hr\n - follow UA and Cultures\n - continue Zosyn for empiric coverage (h/o proteus/pseudomonas UTI)\n .\n # Obstructive cholestasis/cholecystitis: Pt with difficult abd exam,\n decreased bowel sounds and grimaces to exam. CT abd suggestive of\n cholecystitis although Tbili trending down\n - trend LFTs, fractionate bili\n - get MRCP per recs\n - serial abd exams\n .\n # Fecal impaction: hold off on starting bowel regimen for now as pt\n having liquid stool around impaction\n - send for Cdiff\n - consider enema in am\n .\n # s/p PE on coumadin: INR supratherapeutic at 5.0\n - hold coumadin for now, trend coags\n .\n # s/p CVA: pt with \"locked in\" syndrome maintained on Diazepam for\n contractures?\n - hold diazepam for now given recent hypotension\n .\n # FEN: NPO given possible aspiration (hold TF)\n - IVF boluses prn and replete electrolytes aggressively\n .\n # Prophylaxis: INR of 5 and Famotidine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2146-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383921, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline. Cholecystitis treated w/IV abx, as not a candidate for ERCP\n or surgery. Patient is DNR/DNI. Hi is no longer impacted after having\n multiple soft BM\nsfor 2 days. He is called out, awaiting bed.\n Pneumonia, aspiration\n Assessment:\n Patient coughing up thick yellow secretions on his own. O2 sats>93% on\n room air while awake. Dropped to 88% when deeply asleep. Lungs:\n diminished throughout to rhoncorous @ upper lungs.\n Action:\n O2 @ 2L NP applied to bring sats up 96% when asleep. Suctioned mouth\n outside of teeth. Oral care done w/swab to outside of teeth as patient\n clenched teeth shut. Given albuterol & atrovent neb Tx X1. Patient\n kept NPO x meds. CXR @ 0540.\n Response:\n Patient opened his mouth when coughing up secretions, but clenched\n teeth when orally suctioned.\n Plan:\n Take O2 off during the day\n Atrial fibrillation (Afib)\n Assessment:\n HR: 70\ns SR-101^ ST w/frequent PAC\ns & rare PVC. BP stable.\n Action:\n Response:\n Plan:\n Transfer to floor when bed available. IV nurse to place PICC today.\n" }, { "category": "Nursing", "chartdate": "2146-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383649, "text": "This 83 yr old man comes in through the EW w/probable aspiration PNA,\n possible cholecystitis, UTI, probable C-diff infection. PMH: multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal\n resident of Nursing Home.\n Pneumonia, aspiration\n Assessment:\n Received patient on nonrebreather w/O2 sats 96-100%\n Action:\n Placed patient on high flow neb @ % O2.\n Response:\n Plan:\n .H/O constipation (Obstipation, FOS)? Fecal impaction\n Assessment:\n CT showed fecal impaction w/no bowel obstruction. L femoral CVL\n placed for IV access.\n Action:\n Fecal collection bag placed over rectum as patient is constantly oozing\n stool (around impaction). Stool sent for C-diff.\n Response:\n L femoral kept clean.\n Plan:\n Patient needs line placed elsewhere.\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps)\n Action:\n Patient wearing waffle boots. Patient turned q 2 hrs.\n Response:\n Has vascular sores on R foot, otherwise skin is intact. Dressing last\n changed @ nursing home on . Cleaned w/NS & placed adaptic & kerlix\n to wounds. Will change R foot drsg .\n Plan:\n Continue skin care. Consider kinair bed.\n" }, { "category": "Case Management ", "chartdate": "2146-06-28 00:00:00.000", "description": "Case Management Assessment", "row_id": 383726, "text": "TITLE: Case Management Assessment\n The patient is an 83 year-old gentleman with a past medical history of\n CVA and resultant \"locked in\" syndrome, recurrent aspiration PNA and\n UTIs who presented with fever, tachypnea, abdominal distension and\n suspected aspiration event.\n The patient is a long-term care resident at . He is on a\n 10-day Medicaid bed hold and we should expect that he will return there\n once stable. NCM to follow to facilitate the patient\ns return to\n when clinically appropriate.\n Please call/page anytime for case management needs.\n , RN, BSN\n MICU Service Case Manager\n Phone: 2-7925/7-0306\n Pager: \n" }, { "category": "Nursing", "chartdate": "2146-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383910, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline. Cholecystitis treated w/IV abx, as not a candidate for ERCP\n or surgery. Patient is DNR/DNI. He is called out, awaiting bed.\n Pneumonia, aspiration\n Assessment:\n Patient coughing up thick yellow secretions on his own. O2 sats>93% on\n room air while awake. Dropped to 88% when deeply asleep. Lungs:\n diminished throughout to rhoncorous @ upper lungs.\n Action:\n O2 @ 2L NP applied to bring sats up 96% when asleep. Suctioned mouth\n outside of teeth. Oral care done w/swab to outside of teeth as patient\n clenched teeth shut. Given albuterol & atrovent neb Tx X1. Patient\n kept NPO x meds.\n Response:\n Patient opened his mouth when coughing up secretions, but clenched\n teeth when orally suctioned.\n Plan:\n Take O2 off during the day\n Atrial fibrillation (Afib)\n Assessment:\n HR: 70\ns SR-101^ ST w/frequent PAC\ns & rare PVC. BP stable.\n Action:\n Response:\n Plan:\n Transfer to floor when bed available. IV nurse to place PICC today.\n" }, { "category": "Nursing", "chartdate": "2146-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383797, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline.\n No significant overnight events\n Pneumonia, aspiration\n Assessment:\n LS rhonci upper lobes, dimished @ bases, RR 18\n 24 non labored, weak\n productive cough. Jaw remains clenched preventing oral suctioning.\n Satting 100% on 3 L nasal\n Action:\n Administered flagyl/zosyn, no NT suction as pts INR remains elevated @\n this time\n Response:\n Clinical presentation unchanged from above\n Plan:\n Cont to monitor resp status and broad spectrum abx.\n .H/O constipation (Obstipation, FOS)/ Fecal impaction\n Assessment:\n CT from showed fecal impaction without obstruction. Multiple small\n guiac positive stools overnight\n Action:\n No enema/ aggressive bowel regimen @ this time as pt has a L femoral\n tripple lumen for access & abd is soft/nontender\n Response:\n L femoral tripple lumen dsg remains clean, dry and intact. As above\n multiple smal guiac pos. stools.\n Plan:\n Patient needs line placed elsewhere before fecal impaction is treated\n w/enemas etc. ICU team discussing re-site of TLC especially since bld\n cx +.\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps).\n Action:\n Patient wearing heal protectors, waffle boot ordered for left leg as\n noted ulceration on heel. Placed back on nursing home regime of\n baclofen and diazepam.\n Response:\n Has vascular sores on R foot, otherwise skin is intact. Dressing last\n changed @ nursing home on . Cleaned w/NS & placed adaptic & kerlix\n to wounds. Will change R foot drsg .\n Plan:\n Continue skin care. Waffle boot to left foot. Heel protector to right.\n Atrial fibrillation (Afib)\n Assessment:\n Rhythm frequently converts between NSR and Afib w/ multiple bursts of\n rapid ventricular response. Occasional ventricular ectopy evident.\n Burst of RVR typically aggitation/ turning/ suctioning etc. and\n spontaneously rate control quickly achieved once comfortable.\n Action:\n Coumadin held for INR 5.0-5.4. Received 1 U FFP on and 5mg PO\n vitamin K overnight\n Response:\n Awaiting results of morning labs\n Plan:\n Continue to monitor hemodynamic status.\n Pt may go to IR today for perc drain placement as pt is not a candidate\n for ERCP or surgical intervention of cholecystitis.\n" }, { "category": "Nursing", "chartdate": "2146-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383804, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline.\n Overnight\n Lytes repleted w/ 4gm Ca gluconate 40meq KCl IV and 40meq\n KCl PO\n Large BM @ 0400\n Pneumonia, aspiration\n Assessment:\n LS rhonci upper lobes, dimished @ bases, RR 18\n 24 non labored, weak\n productive cough. Jaw remains clenched preventing oral suctioning.\n Satting 100% on 3 L nasal\n Action:\n Administered flagyl/zosyn, no NT suction as pts INR remains elevated @\n this time\n Response:\n Clinical presentation unchanged from above\n Plan:\n Cont to monitor resp status and broad spectrum abx.\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps).\n Action:\n Patient wearing heal protectors, waffle boot ordered for left leg as\n noted ulceration on heel. Placed back on nursing home regime of\n baclofen and diazepam.\n Response:\n Has vascular sores on R foot, otherwise skin is intact. Dressing last\n changed @ nursing home on . Cleaned w/NS & placed adaptic & kerlix\n to wounds. Will change R foot drsg .\n Plan:\n Continue skin care. Waffle boot to left foot. Heel protector to right.\n Atrial fibrillation (Afib)\n Assessment:\n Rhythm frequently converts between NSR and Afib w/ multiple bursts of\n rapid ventricular response. Occasional ventricular ectopy evident.\n Burst of RVR typically aggitation/ turning/ suctioning etc. and\n spontaneously rate control quickly achieved once comfortable.\n Action:\n Coumadin held for INR 5.0-5.4. Received 1 U FFP on and 5mg PO\n vitamin K overnight\n Response:\n Awaiting results of morning labs\n Plan:\n Continue to monitor hemodynamic status.\n Pt may go to IR today for perc drain placement as pt is not a candidate\n for ERCP or surgical intervention of cholecystitis.\n" }, { "category": "Nursing", "chartdate": "2146-06-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 383987, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline. Cholecystitis treated w/IV abx, as not a candidate for ERCP\n or surgery. Patient is DNR/DNI. He is no longer impacted after having\n multiple soft BM\nsfor 2 days.\n Atrial fibrillation (Afib)\n Assessment:\n Pt noted to be in SR w/rate 70-80s, no VEA noted, however, does appear\n to have paroxysmal afb w/rate as high as 150s, no compromise in b/p\n noted.\n Action:\n Electrolytes being repleted as ordered.\n Response:\n Conts to have paroxysmal Afib w/RVR, no noted compromise in b/p noted.\n Plan:\n Cont to monitor hemodynamics.\n Pneumonia, aspiration\n Assessment:\n Patient coughing up thick yellow secretions on his own. O2 sats>93% on\n room air while awake. Dropped to 88% when deeply asleep. Lungs:\n diminished throughout to rhoncorous @ upper lungs.\n Action:\n O2 @ 2L NP applied to bring sats up 96% when asleep. Suctioned mouth\n outside of teeth. Oral care done w/swab to outside of teeth as patient\n clenched teeth shut. Given albuterol & atrovent neb Tx X1. Patient\n kept NPO x meds.\n Response:\n Patient opened his mouth when coughing up secretions, but clenched\n teeth when orally suctioned or mouth swabs inserted into mouth.\n Plan:\n Take O2 off during the day, monitor O2 sats.\n H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps) appears to\n grind teeth with repositioning. Pt does not appear to communicate as\n per history\nlocked in syndrome.\n Action:\n Patient wearing heal protector on right , waffle boot for left leg as\n noted ulceration on heel, ulcers on upper foot remain present, adaptic\n and stockingnet applied daily after cleansing w/wound cleanser. Placed\n back on nursing home regime of baclofen and diazepam for contractures.\n Response:\n Has vascular sores on L foot, otherwise skin is intact. Cleaned w/NS\n or wound cleanser & placed adaptic & stockingnet to wounds. Will\n change L foot drsg .\n Plan:\n Continue skin care. Turn and position q2h. Waffle boot to left foot.\n Heel protector to right. Left foot dressing change qd. G-tube DSD QD.\n PICC double lumen catheter placed\n AC, await CXR confirmation.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n URINARY TRACT INFECTION\n Code status:\n Height:\n Admission weight:\n 82.4 kg\n Daily weight:\n 85.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH:\n CV-PMH: CVA\n Additional history: s/p CVA w/dysphagia & \"locked in \" syndrome,\n dementia, PE, aspiration PNA, recurrent slin ulcer, atypical psychosis,\n depression, constipation, thoracic aortic anuerysm, recurrent UTI's\n including proteus, G-tube issues.\n Surgery / Procedure and date: new PEG tube placed\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:55\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 922 mL\n 24h total out:\n 945 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:08 AM\n Potassium:\n 2.5 mEq/L\n 04:08 AM\n Chloride:\n 111 mEq/L\n 04:08 AM\n CO2:\n 24 mEq/L\n 04:08 AM\n BUN:\n 37 mg/dL\n 04:08 AM\n Creatinine:\n 1.3 mg/dL\n 04:08 AM\n Glucose:\n 127 mg/dL\n 04:08 AM\n Hematocrit:\n 25.3 %\n 04:08 AM\n Finger Stick Glucose:\n 105\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 11R\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2146-06-30 00:00:00.000", "description": "Resident Note", "row_id": 383988, "text": "TITLE:\n TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:57 AM\n MULTI LUMEN - STOP 05:00 AM\n -No surgical or IR intervention\n -Continue abx\n -Pt called out to surgery\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Metronidazole - 04:00 AM\n Piperacillin/Tazobactam (Zosyn) - 05:30 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.5\n HR: 70 (62 - 101) bpm\n BP: 101/46(59) {95/42(57) - 140/67(85)} mmHg\n RR: 18 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.6 kg (admission): 82.4 kg\n Total In:\n 1,425 mL\n 240 mL\n PO:\n TF:\n IVF:\n 1,185 mL\n 210 mL\n Blood products:\n Total out:\n 1,995 mL\n 525 mL\n Urine:\n 1,995 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -285 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General: eyes open, grimaces to exam, no response to verbal stim\n HEENT: Sclera anicteric, eyes follow examiner\n Neck: supple, unable to assess JVP\n Lungs: audible upper airway secretions with rhonchi, L sided wheezes,\n abd breathing\n CV: RRR, unable to appreciate murmurs through upper airway sounds\n Abdomen: soft, non-distended, bowel sounds audible, no grimaces to deep\n palpation,\n GU: foley in place\n Ext: warm, 1+ pulses, no cyanosis or edema.\n Labs / Radiology\n 179 K/uL\n 8.8 g/dL\n 127 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 2.5 mEq/L\n 37 mg/dL\n 111 mEq/L\n 145 mEq/L\n 25.3 %\n 18.7 K/uL\n [image002.jpg]\n 11:42 PM\n 12:31 AM\n 04:49 AM\n 04:28 PM\n 10:53 PM\n 05:04 AM\n 04:08 AM\n WBC\n 28.6\n 26.3\n 25.5\n 22.3\n 18.7\n Hct\n 32.6\n 30.7\n 26.9\n 28.1\n 28.3\n 25.3\n Plt\n 166\n 156\n 155\n 160\n 179\n Cr\n 1.9\n 1.7\n 1.6\n 1.5\n 1.3\n TropT\n 0.03\n 0.02\n 0.01\n TCO2\n 21\n Glucose\n 123\n 107\n 128\n 123\n 127\n Other labs: PT / PTT / INR:28.8/47.3/2.8, CK / CKMB /\n Troponin-T:400/9/0.01, ALT / AST:21/29, Alk Phos / T Bili:60/0.8,\n Amylase / Lipase:37/11, Differential-Neuts:94.3 %, Lymph:1.3 %,\n Mono:3.2 %, Eos:0.1 %, D-dimer:962 ng/mL, Fibrinogen:736 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:2.6 g/dL, LDH:177 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.3 mg/dL\n HIDA : Acute Cholecystitis\n .\n C. diff negative x2\n .\n MRSA screen positive\n .\n BCx \n gram + cocci in pairs and clusters (anaerobic bottle)-\n speciation pending\n BCx \n NGTD\n Femoral line removal and tip sent for culture - pending\n .\n UCx- NGTD\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n .H/O CONSTIPATION (OBSTIPATION, FOS)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), OTHER\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n .H/O DEPRESSION\n PNEUMONIA, ASPIRATION\n .H/O AORTIC ANEURYSM, THORACIC (TAA)\n 83 y/o M with PMhx of CVA, Recurrent Aspiration and UTIs who presented\n with fever, tachypnea and suspected aspiration now with CT abd\n concerning for cholecystitis.\n .\n # Fever/Leukocytosis: Improving. Pt afebrile with decreasing white\n count. be due to acute cholecystitis and/or aspiration pneumonia\n and/or UTI. MRSA screen was positive. Fem line tip sent for cultures\n - f/u urine, blood cx\n - continue empiric Vanc/Zosyn, Flagyl\n - bolus IVF prn\n - goal UOP>30cc/hr\n - trend lactate, CBC, LFTs\n - aggressive pulm toilet\n - blood cultures ordered for today\n .\n # Obstructive cholestasis/cholecystitis: HIDA suggests acute\n cholecystitis. No surgical intervention at this time. No need for\n percutaneous cholecystostomy, but if deteriorates will reconsider.\n - trend LFTs, fractionate bili\n - follow abd exam\n - continue antibiotics for acute cholecystitis for 14 day course\n .\n # Hypoxia: resolving. Most likely due to aspiration pneumonia\n - cover empirically with Vanc/Zosyn\n - albuterol/atrovent nebs for wheezes\n - attempt pulm toilet\n - hold off on diuresis given recent hypotension\n - CXR in AM\n .\n # ARF: improving\n - bolus IVF\n - goal UOP of >30cc/hr\n - follow UCx\n - continue Zosyn for empiric coverage (h/o proteus/pseudomonas UTI)\n .\n # Fecal impaction: hold off on starting bowel regimen for now as pt\n having liquid stool around impaction\n - consider enema\n .\n # s/p PE on coumadin: INR continues to be supratherapeutic at 4.3.\n Received Vitamin K and FFP for possible IR procedure.\n - hold coumadin for now, trend coags\n .\n # s/p CVA: pt with \"locked in\" syndrome maintained on Diazepam for\n contractures.\n - continue diazepam 2mg PO daily\n .\n # Hypokalemia\n K of 2.5 this AM, to be repleted with total of 130 mEq\n of K\n - monitor K\n .\n # FEN: NPO given possible aspiration (hold TF)\n - IVF boluses PRN and replete electrolytes aggressively\n - t/b with surgery re: nutrition\n ICU Care\n Nutrition: NPO for possible aspiration\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 05:19 PM\n Prophylaxis:\n DVT: p-boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: wife\n status: DNR/DNI\n Disposition: call out to floor\n" }, { "category": "Nursing", "chartdate": "2146-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383890, "text": "Pneumonia, aspiration\n Assessment:\n Pt on 2l with sats 98%, ls rhoncherous, pt unable to clear secretions,\n will not let staff oral suction\n Action:\n Frequent turning, chest pt,\n Response:\n Pt coughing and expectorating some thick whiteish secretions, unable to\n oral suction pt, slight wheee noted in bases in afternoon and pt\n received alb/atrrov neb, o2 weaned to ra with sats 100%\n Plan:\n Cont with aggressive pulm toilet, cont to monitor o2 sats and resp\n status, tx as needed\n .H/O constipation (Obstipation, FOS)\n Assessment:\n Per night shift pt had large bm overnight, pt admitted with\n cholecystitis\n Action:\n Due to cholecystitis no tf started\n Response:\n Pt being tx with antibiotics, no perc drain will be placed, pt remains\n npo, pt has had numerous small bm thru out shift, loose soft brown\n stools\n Plan:\n Team to check with surgery ? restarting tf, cont with antibiotics,\n Pt given dose of vit K for continued high INR 5 range, picc line on\n hold, 18 guage placed in right arm and femoral central line can be dc\n and tip sent for cx see poe for orders\n" }, { "category": "Nursing", "chartdate": "2146-06-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 383980, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline. Cholecystitis treated w/IV abx, as not a candidate for ERCP\n or surgery. Patient is DNR/DNI. He is no longer impacted after having\n multiple soft BM\nsfor 2 days.\n Atrial fibrillation (Afib)\n Assessment:\n Pt noted to be in SR w/rate 70-80s, no VEA noted, however, does appear\n to have paroxysmal afb w/rate as high as 150s, no compromise in b/p\n noted.\n Action:\n Electrolytes being repleted as ordered\n Response:\n Conts to have paroxysmal Afib w/RVR, no noted compromise in b/p noted.\n Plan:\n Cont to monitor hemodynamics.\n Pneumonia, aspiration\n Assessment:\n Patient coughing up thick yellow secretions on his own. O2 sats>93% on\n room air while awake. Dropped to 88% when deeply asleep. Lungs:\n diminished throughout to rhoncorous @ upper lungs.\n Action:\n O2 @ 2L NP applied to bring sats up 96% when asleep. Suctioned mouth\n outside of teeth. Oral care done w/swab to outside of teeth as patient\n clenched teeth shut. Given albuterol & atrovent neb Tx X1. Patient\n kept NPO x meds.\n Response:\n Patient opened his mouth when coughing up secretions, but clenched\n teeth when orally suctioned or mouth swabs inserted into mouth.\n Plan:\n Take O2 off during the day, monitor O2 sats.\n" }, { "category": "Nursing", "chartdate": "2146-06-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 383981, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline. Cholecystitis treated w/IV abx, as not a candidate for ERCP\n or surgery. Patient is DNR/DNI. He is no longer impacted after having\n multiple soft BM\nsfor 2 days.\n Atrial fibrillation (Afib)\n Assessment:\n Pt noted to be in SR w/rate 70-80s, no VEA noted, however, does appear\n to have paroxysmal afb w/rate as high as 150s, no compromise in b/p\n noted.\n Action:\n Electrolytes being repleted as ordered\n Response:\n Conts to have paroxysmal Afib w/RVR, no noted compromise in b/p noted.\n Plan:\n Cont to monitor hemodynamics.\n Pneumonia, aspiration\n Assessment:\n Patient coughing up thick yellow secretions on his own. O2 sats>93% on\n room air while awake. Dropped to 88% when deeply asleep. Lungs:\n diminished throughout to rhoncorous @ upper lungs.\n Action:\n O2 @ 2L NP applied to bring sats up 96% when asleep. Suctioned mouth\n outside of teeth. Oral care done w/swab to outside of teeth as patient\n clenched teeth shut. Given albuterol & atrovent neb Tx X1. Patient\n kept NPO x meds.\n Response:\n Patient opened his mouth when coughing up secretions, but clenched\n teeth when orally suctioned or mouth swabs inserted into mouth.\n Plan:\n Take O2 off during the day, monitor O2 sats.\n H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps) appears to\n grind teeth with repositioning. Pt does not appear to communicate as\n per history\nlocked in syndrome.\n Action:\n Patient wearing heal protector on right , waffle boot for left leg as\n noted ulceration on heel, ulcers on upper foot remain present, adaptic\n and stockingnet applied daily after cleansing w/wound cleanser. Placed\n back on nursing home regime of baclofen and diazepam for contractures.\n Response:\n Has vascular sores on L foot, otherwise skin is intact. Cleaned w/NS\n or wound cleanser & placed adaptic & stockingnet to wounds. Will\n change L foot drsg .\n Plan:\n Continue skin care. Turn and position q2h. Waffle boot to left foot.\n Heel protector to right. Left foot dressing change qd. G-tube DSD QD.\n" }, { "category": "Nursing", "chartdate": "2146-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383773, "text": "This 83 yr old man comes in through the EW w/probable aspiration PNA,\n possible cholecystitis, UTI, probable C-diff infection. PMH: multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal\n resident of Nursing Home. Pt has +bld cxs and\n cholangitis.\n Pneumonia, aspiration\n Assessment:\n Received patient on 40% hi flow neb w/ O2 sats 96%+, O2 removed during\n rounds and although O2 sats 95-97%, O2 2L NC placed d/t intermittant\n apparent afib w/RVR to 170s\n Action:\n RA O2 sats appear adequate, however, no ABG. O2 2L NC placed d/t\n cardiac demand. RT suctioned patient nasotracheally for moderate amount\n of thick yellow secretions overnight and no NT suctioning w/INR >5.\n Only suctioning oral secretions from mouth, although patient grinding\n teeth and fighting against any oral care.\n Response:\n RA sats appear adequate, O2 2L NC placed.\n Plan:\n Continue to titrate O2 down as tolerated.\n .H/O constipation (Obstipation, FOS)/ Fecal impaction\n Assessment:\n CT showed fecal impaction w/no bowel obstruction. L femoral CVL\n placed for IV access in EW. Cont to ooz mod amt liquid stool, small\n amount stool disempaction this morning, however, noted blood hue on pad\n under stool and disempaction on hold at present. G-tube to gravity\n draining bile, discussed w/ICU team and G-tube now clamped and given\n first g-tube meds at 1800.\n Action:\n Turn and position q2 hour w/cleaning for stool at least q2hour.\n Response:\n L femoral CVL kept clean.\n Plan:\n Patient needs line placed elsewhere before fecal impaction is treated\n w/enemas etc. ICU team discussing re-site of TLC especially since bld\n cx +. Monitor tolerance to g-tube being clamped and med administration.\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps).\n Action:\n Patient wearing heal protectors, waffle boot ordered for left leg as\n noted ulceration on heel. Placed back on nursing home regime of\n baclofen and diazepam.\n Response:\n Has vascular sores on R foot, otherwise skin is intact. Dressing last\n changed @ nursing home on . Cleaned w/NS & placed adaptic & kerlix\n to wounds. Will change R foot drsg .\n Plan:\n Continue skin care. Waffle boot to left foot. Heel protector to right.\n Atrial fibrillation (Afib)\n Assessment:\n HR: 80s-100 SR w/occasional PVCs, noted intermittant episodes of afib\n w/RVR w/rate as high as 170s, pt received total of 1500CC LR\n w/improvement of less frequent episodes of afib w/RVR.\n Action:\n Coumadin held for INR 5.0-5.4. FFP for ^INR and OB+ stool w/red\n blood hue of stool on bed linens.\n Response:\n Await 1700 INR.\n Plan:\n Continue to monitor HR, rhythm. IVF appears to help w/RVR\n" }, { "category": "Nursing", "chartdate": "2146-06-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 383979, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline. Cholecystitis treated w/IV abx, as not a candidate for ERCP\n or surgery. Patient is DNR/DNI. He is no longer impacted after having\n multiple soft BM\nsfor 2 days.\n Atrial fibrillation (Afib)\n Assessment:\n Pt noted to be in SR w/rate 70-80s, no VEA noted, however, does appear\n to have paroxysmal afb w/rate as high as 150s, no compromise in b/p\n noted.\n Action:\n Electrolytes being repleted as ordered\n Response:\n Conts to have paroxysmal Afib w/RVR, no noted compromise in b/p noted.\n Plan:\n Cont to monitor hemodynamics.\n" }, { "category": "Nursing", "chartdate": "2146-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 384030, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline. Cholecystitis treated w/IV abx, as not a candidate for ERCP\n or surgery. Patient is DNR/DNI. He is no longer impacted after having\n multiple soft BM\nsfor 2 days.\n Atrial fibrillation (Afib)\n Assessment:\n Pt noted to be in SR w/rate 70-80s, no VEA noted, however, does appear\n to have paroxysmal afb w/rate as high as 150s, no compromise in b/p\n noted.\n Action:\n Electrolytes being repleted as ordered.\n Response:\n Conts to have paroxysmal Afib w/RVR, no noted compromise in b/p noted.\n Plan:\n Cont to monitor hemodynamics.\n Pneumonia, aspiration\n Assessment:\n Patient coughing up thick yellow secretions on his own. O2 sats>93% on\n room air while awake. Dropped to 88% when deeply asleep. Lungs:\n diminished throughout to rhoncorous @ upper lungs.\n Action:\n O2 @ 2L NP applied to bring sats up 96% when asleep. Suctioned mouth\n outside of teeth. Oral care done w/swab to outside of teeth as patient\n clenched teeth shut. Given albuterol & atrovent neb Tx X1. Patient\n kept NPO x meds.\n Response:\n Patient opened his mouth when coughing up secretions, but clenched\n teeth when orally suctioned or mouth swabs inserted into mouth.\n Plan:\n Take O2 off during the day, monitor O2 sats.\n H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps) appears to\n grind teeth with repositioning. Pt does not appear to communicate as\n per history\nlocked in syndrome.\n Action:\n Patient wearing heal protector on right , waffle boot for left leg as\n noted ulceration on heel, ulcers on upper foot remain present, adaptic\n and stockingnet applied daily after cleansing w/wound cleanser. Placed\n back on nursing home regime of baclofen and diazepam for contractures.\n Response:\n Has vascular sores on L foot, otherwise skin is intact. Cleaned w/NS\n or wound cleanser & placed adaptic & stockingnet to wounds. Will\n change L foot drsg .\n Plan:\n Continue skin care. Turn and position q2h. Waffle boot to left foot.\n Heel protector to right. Left foot dressing change qd. G-tube DSD QD.\n PICC double lumen catheter placed\n AC, CXR confirmed, bld cx\ns sent\n via line +MRSA bld cxs.\n" }, { "category": "Physician ", "chartdate": "2146-06-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 383984, "text": "Chief Complaint: Cholecystitis, acute renal failure, afib\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Remains afebrile. WBC coming down.\n One blood culture positive for staph. Femoral line pulled. PIC line\n being placed.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:57 AM\n MULTI LUMEN - STOP 05:00 AM\n History obtained from Medical records\n Patient unable to provide history: s/p CVA\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Metronidazole - 04:00 AM\n Piperacillin/Tazobactam (Zosyn) - 11:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:48 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 77 (62 - 148) bpm\n BP: 119/55(70) {87/40(52) - 140/67(85)} mmHg\n RR: 18 (14 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.6 kg (admission): 82.4 kg\n Total In:\n 1,425 mL\n 787 mL\n PO:\n TF:\n IVF:\n 1,185 mL\n 577 mL\n Blood products:\n Total out:\n 1,995 mL\n 945 mL\n Urine:\n 1,995 mL\n 945 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -158 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: Unable to examine patient who is having PIC line\n placed.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.8 g/dL\n 179 K/uL\n 127 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 2.5 mEq/L\n 37 mg/dL\n 111 mEq/L\n 145 mEq/L\n 25.3 %\n 18.7 K/uL\n [image002.jpg]\n 11:42 PM\n 12:31 AM\n 04:49 AM\n 04:28 PM\n 10:53 PM\n 05:04 AM\n 04:08 AM\n WBC\n 28.6\n 26.3\n 25.5\n 22.3\n 18.7\n Hct\n 32.6\n 30.7\n 26.9\n 28.1\n 28.3\n 25.3\n Plt\n 166\n 156\n 155\n 160\n 179\n Cr\n 1.9\n 1.7\n 1.6\n 1.5\n 1.3\n TropT\n 0.03\n 0.02\n 0.01\n TCO2\n 21\n Glucose\n 123\n 107\n 128\n 123\n 127\n Other labs: PT / PTT / INR:28.8/47.3/2.8, CK / CKMB /\n Troponin-T:400/9/0.01, ALT / AST:21/29, Alk Phos / T Bili:60/0.8,\n Amylase / Lipase:37/11, Differential-Neuts:94.3 %, Lymph:1.3 %,\n Mono:3.2 %, Eos:0.1 %, D-dimer:962 ng/mL, Fibrinogen:736 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:2.6 g/dL, LDH:177 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n .H/O CONSTIPATION (OBSTIPATION, FOS)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), OTHER\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n .H/O DEPRESSION\n PNEUMONIA, ASPIRATION\n .H/O AORTIC ANEURYSM, THORACIC (TAA)\n CHOLECYSTITIS\n ACUTE RENAL FAILURE\n ANEMIA\n ========================\n Patient doing well on present antibiotics. WBC improving. Continue\n antibiotics. One blood culture was positive for staph. Femoral line\n removed. Needs additional cultures.\n Hct down mildly; no evidence of bleeding.\n Creatinine improving with fluids.\n Patient to be transferred to surgical floor.\n Repleting potassium.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments: Not applicable\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition :Transfer to floor\n Total time spent: 25 minutes\n" }, { "category": "Nursing", "chartdate": "2146-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 384034, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline. Cholecystitis treated w/IV abx, as not a candidate for ERCP\n or surgery. Patient is DNR/DNI. Hi is no longer impacted after having\n multiple soft BM\nsfor 2 days. He is called out, awaiting bed.\n Pneumonia, aspiration\n Assessment:\n Patient coughing up thick yellow secretions on his own. O2 sats>93% on\n room air while awake. Dropped to 88% when deeply asleep. Lungs:\n diminished throughout to rhoncorous @ upper lungs.\n Action:\n O2 @ 2L NP applied to bring sats up 96% when asleep. Suctioned mouth\n outside of teeth. Oral care done w/swab to outside of teeth as patient\n clenched teeth shut. Given albuterol & atrovent neb Tx X1. Patient\n kept NPO x meds. CXR @ 0540.\n Response:\n Patient opened his mouth when coughing up secretions, but clenched\n teeth when orally suctioned.\n Plan:\n Take O2 off during the day\n Atrial fibrillation (Afib)\n Assessment:\n HR: 70\ns SR-101^ ST w/frequent PAC\ns & rare PVC. BP stable.\n Action:\n Response:\n Plan:\n Transfer to floor when bed available. IV nurse to place PICC today.\n" }, { "category": "Nursing", "chartdate": "2146-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 384038, "text": "83 y/o M presented to ED from w/ probable aspiration\n PNA, & cholecystitis. Mr has a PMH significant for multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal @\n baseline.\n Overnight\n Lytes repleted w/ 4gm Ca gluconate 40meq KCl IV and 40meq\n KCl PO\n Large BM @ 0400\n Pneumonia, aspiration\n Assessment:\n LS rhonci upper lobes, dimished @ bases, RR 18\n 24 non labored, weak\n productive cough. Jaw remains clenched preventing oral suctioning.\n Satting 100% on 3 L nasal\n Action:\n Administered flagyl/zosyn, no NT suction as pts INR remains elevated @\n this time\n Response:\n Clinical presentation unchanged from above\n Plan:\n Cont to monitor resp status and broad spectrum abx.\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps).\n Action:\n Patient wearing heal protectors, waffle boot ordered for left leg as\n noted ulceration on heel. Placed back on nursing home regime of\n baclofen and diazepam.\n Response:\n Has vascular sores on R foot, otherwise skin is intact. Dressing last\n changed @ nursing home on . Cleaned w/NS & placed adaptic & kerlix\n to wounds. Will change R foot drsg .\n Plan:\n Continue skin care. Waffle boot to left foot. Heel protector to right.\n Atrial fibrillation (Afib)\n Assessment:\n Rhythm frequently converts between NSR and Afib w/ multiple bursts of\n rapid ventricular response. Occasional ventricular ectopy evident.\n Burst of RVR typically aggitation/ turning/ suctioning etc. and\n spontaneously rate control quickly achieved once comfortable.\n Action:\n Coumadin held for INR 5.0-5.4. Received 1 U FFP on and 5mg PO\n vitamin K overnight\n Response:\n Awaiting results of morning labs\n Plan:\n Continue to monitor hemodynamic status.\n Pt may go to IR today for perc drain placement as pt is not a candidate\n for ERCP or surgical intervention of cholecystitis.\n" }, { "category": "Nursing", "chartdate": "2146-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383765, "text": "This 83 yr old man comes in through the EW w/probable aspiration PNA,\n possible cholecystitis, UTI, probable C-diff infection. PMH: multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal\n resident of Nursing Home. Pt has +bld cxs and\n cholangitis.\n Pneumonia, aspiration\n Assessment:\n Received patient on 40% hi flow neb w/ O2 sats 96%+, O2 removed during\n rounds and although O2 sats 95-97%, O2 2L NC placed d/t intermittant\n apparent afib w/RVR to 170s\n Action:\n RA O2 sats appear adequate, however, no ABG. O2 2L NC placed d/t\n cardiac demand. RT suctioned patient nasotracheally for moderate amount\n of thick yellow secretions overnight and no NT suctioning w/INR >5.\n Only suctioning oral secretions from mouth, although patient grinding\n teeth and fighting against any oral care.\n Response:\n RA sats appear adequate, O2 2L NC placed.\n Plan:\n Continue to titrate O2 down as tolerated.\n .H/O constipation (Obstipation, FOS)/ Fecal impaction\n Assessment:\n CT showed fecal impaction w/no bowel obstruction. L femoral CVL\n placed for IV access in EW. Cont to ooz mod amt liquid stool, small\n amount stool disempaction this morning, however, noted blood hue on pad\n under stool and disempaction on hold at present.\n Action:\n Turn and position q2 hour w/cleaning for stool at least q2hour.\n Response:\n L femoral CVL kept clean.\n Plan:\n Patient needs line placed elsewhere before fecal impaction is treated\n w/enemas etc. ICU team discussing re-site of TLC especially since bld\n cx +\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps).\n Action:\n Patient wearing heal protectors, waffle boot ordered for left leg as\n noted ulceration on heel. Placed back on nursing home regime of\n baclofen and diazepam.\n Response:\n Has vascular sores on R foot, otherwise skin is intact. Dressing last\n changed @ nursing home on . Cleaned w/NS & placed adaptic & kerlix\n to wounds. Will change R foot drsg .\n Plan:\n Continue skin care. Waffle boot to left foot. Heel protector to right.\n Atrial fibrillation (Afib)\n Assessment:\n HR: 80s-100 SR w/occasional PVCs, noted intermittant episodes of afib\n w/RVR w/rate as high as 170s, pt received total of 1500CC LR\n w/improvement of less frequent episodes of afib w/RVR.\n Action:\n Coumadin held for INR 5.0-5.4. FFP for ^INR and OB+ stool w/red\n blood hue of stool on bed linens.\n Response:\n Await 1700 INR.\n Plan:\n Continue to monitor HR, rhythm. IVF appears to help w/RVR\n" }, { "category": "Physician ", "chartdate": "2146-06-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 383869, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 02:00 PM\n - HIDA scan showed acute cholecystitis, not candidate for surgery given\n multiple comorbidities. IR contact for percutaneous cholecystostomy,\n but INR was 5.3, needs to be 1.5\n - gave vitamin K to bring down INR\n - given 1 unit FFP for possible line, PICC in the AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin/Tazobactam (Zosyn) - 05:37 AM\n Vancomycin\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Morphine Sulfate - 03:35 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 74 (74 - 145) bpm\n BP: 111/57(69) {96/43(55) - 133/71(79)} mmHg\n RR: 18 (17 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.6 kg (admission): 82.4 kg\n Total In:\n 5,687 mL\n 458 mL\n PO:\n TF:\n IVF:\n 5,250 mL\n 368 mL\n Blood products:\n 257 mL\n Total out:\n 3,065 mL\n 510 mL\n Urine:\n 2,590 mL\n 510 mL\n NG:\n 475 mL\n Stool:\n Drains:\n Balance:\n 2,622 mL\n -52 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 1L\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n General: eyes open, grimaces to exam, no response to verbal stim\n HEENT: Sclera anicteric, eyes follow examiner\n Neck: supple, unable to assess JVP\n Lungs: audible upper airway secretions with rhonchi, L sided wheezes,\n abd breathing\n CV: RRR, unable to appreciate murmurs through upper airway sounds\n Abdomen: soft, non-distended, bowel sounds audible, no grimaces to deep\n palpation,\n GU: foley in place\n Ext: warm, 1+ pulses, no cyanosis or edema.\n Labs / Radiology\n 160 K/uL\n 9.5 g/dL\n 123 mg/dL\n 1.5 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 110 mEq/L\n 142 mEq/L\n 28.3 %\n 22.3 K/uL\n [image002.jpg]\n \n 5am.\n 11:42 PM\n 12:31 AM\n 04:49 AM\n 04:28 PM\n 10:53 PM\n 05:04 AM\n WBC\n 28.6\n 26.3\n 25.5\n 22.3\n Hct\n 32.6\n 30.7\n 26.9\n 28.1\n 28.3\n Plt\n 166\n 156\n 155\n 160\n Cr\n 1.9\n 1.7\n 1.6\n 1.5\n TropT\n 0.03\n 0.02\n 0.01\n TCO2\n 21\n Glucose\n 123\n 107\n 128\n 123\n Other labs: PT / PTT / INR:41.1/54.6/4.3, CK / CKMB /\n Troponin-T:400/9/0.01, ALT / AST:24/43, Alk Phos / T Bili:50/0.9,\n Amylase / Lipase:37/11, Differential-Neuts:94.3 %, Lymph:1.3 %,\n Mono:3.2 %, Eos:0.1 %, D-dimer:962 ng/mL, Fibrinogen:736 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:2.6 g/dL, LDH:177 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.1 mg/dL\n .\n HIDA : Acute Cholecystitis\n .\n CXR : increased consolidation at Right lung base\n .\n C. diff negative x2\n .\n MRSA\n pending\n .\n BCx \n gram + cocci in pairs and clusters (anaerobic bottle)-\n speciation pending\n BCx - NGTD\n .\n UCx- NGTD\n Assessment and Plan\n 83 y/o M with PMhx of CVA, Recurrent Aspiration and UTIs who presented\n with fever, tachypnea and suspected aspiration now with CT abd\n concerning for cholecystitis.\n .\n # Fever/Leukocytosis: Improving. Pt afebrile with decreasing white\n count. be due to acute cholecystitis and/or aspiration pneumonia\n and/or UTI.\n - f/u urine, blood cx\n - continue empiric Vanc/Zosyn, Flagyl\n - repeat CXR in am\n - bolus IVF prn\n - goal UOP>30cc/hr\n - trend lactate, CBC, LFTs\n - aggressive pulm toilet\n .\n # Obstructive cholestasis/cholecystitis: HIDA suggests acute\n cholecystitis. No surgical intervention at this time. No need for\n percutaneous cholecystostomy.\n - trend LFTs, fractionate bili\n - follow abd exam\n -continue antibiotics for acute cholecystitis\n .\n # Hypoxia: resolving. Most likely due to aspiration pneumonia\n - cover empirically with Vanc/Zosyn\n - albuterol/atrovent nebs for wheezes\n - attempt pulm toilet\n - hold off on diuresis given recent hypotension\n - CXR in AM\n .\n # ARF: improving\n - bolus IVF\n - goal UOP of >30cc/hr\n - follow UCx\n - continue Zosyn for empiric coverage (h/o proteus/pseudomonas UTI)\n .\n # Fecal impaction: hold off on starting bowel regimen for now as pt\n having liquid stool around impaction\n - consider enema\n .\n # s/p PE on coumadin: INR continues to be supratherapeutic at 4.3.\n Received Vitamin K and FFP for possible IR procedure.\n - hold coumadin for now, trend coags\n .\n # s/p CVA: pt with \"locked in\" syndrome maintained on Diazepam for\n contractures.\n - continue diazepam 2mg PO daily\n .\n # FEN: NPO given possible aspiration (hold TF)\n - IVF boluses PRN and replete electrolytes aggressively\n - t/b with surgery re: nutrition\n ICU Care\n Nutrition: NPO given possible aspiration\n Glycemic Control: ISS\n Lines:\n Multi Lumen Femoral - 11:30 PM\n will contact IV nurse re:\n PICC placement given supratherapeutic INR and d/c femoral line\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: Famotidine\n VAP:\n Comments:\n Communication: Comments: Pt and wife\n status: DNR/DNI\n Disposition: call out to floor for further care\n" }, { "category": "Physician ", "chartdate": "2146-06-30 00:00:00.000", "description": "Resident Note", "row_id": 383952, "text": "TITLE:\n TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:57 AM\n MULTI LUMEN - STOP 05:00 AM\n -No surgical or IR intervention\n -Continue abx\n -Pt called out to medicine floor - no beds available\n - Pending: Femoral line removal and tip sent for culture\n - Surgery: if deteriorates - think of perc chole tube\n - Surgery: 14d course of abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Metronidazole - 04:00 AM\n Piperacillin/Tazobactam (Zosyn) - 05:30 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.5\n HR: 70 (62 - 101) bpm\n BP: 101/46(59) {95/42(57) - 140/67(85)} mmHg\n RR: 18 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.6 kg (admission): 82.4 kg\n Total In:\n 1,425 mL\n 240 mL\n PO:\n TF:\n IVF:\n 1,185 mL\n 210 mL\n Blood products:\n Total out:\n 1,995 mL\n 525 mL\n Urine:\n 1,995 mL\n 525 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -285 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General: eyes open, grimaces to exam, no response to verbal stim\n HEENT: Sclera anicteric, eyes follow examiner\n Neck: supple, unable to assess JVP\n Lungs: audible upper airway secretions with rhonchi, L sided wheezes,\n abd breathing\n CV: RRR, unable to appreciate murmurs through upper airway sounds\n Abdomen: soft, non-distended, bowel sounds audible, no grimaces to deep\n palpation,\n GU: foley in place\n Ext: warm, 1+ pulses, no cyanosis or edema.\n Labs / Radiology\n 179 K/uL\n 8.8 g/dL\n 127 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 2.5 mEq/L\n 37 mg/dL\n 111 mEq/L\n 145 mEq/L\n 25.3 %\n 18.7 K/uL\n [image002.jpg]\n 11:42 PM\n 12:31 AM\n 04:49 AM\n 04:28 PM\n 10:53 PM\n 05:04 AM\n 04:08 AM\n WBC\n 28.6\n 26.3\n 25.5\n 22.3\n 18.7\n Hct\n 32.6\n 30.7\n 26.9\n 28.1\n 28.3\n 25.3\n Plt\n 166\n 156\n 155\n 160\n 179\n Cr\n 1.9\n 1.7\n 1.6\n 1.5\n 1.3\n TropT\n 0.03\n 0.02\n 0.01\n TCO2\n 21\n Glucose\n 123\n 107\n 128\n 123\n 127\n Other labs: PT / PTT / INR:28.8/47.3/2.8, CK / CKMB /\n Troponin-T:400/9/0.01, ALT / AST:21/29, Alk Phos / T Bili:60/0.8,\n Amylase / Lipase:37/11, Differential-Neuts:94.3 %, Lymph:1.3 %,\n Mono:3.2 %, Eos:0.1 %, D-dimer:962 ng/mL, Fibrinogen:736 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:2.6 g/dL, LDH:177 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.3 mg/dL\n HIDA : Acute Cholecystitis\n .\n CXR : increased consolidation at Right lung base\n .\n C. diff negative x2\n .\n MRSA\n pending\n .\n BCx \n gram + cocci in pairs and clusters (anaerobic bottle)-\n speciation pending\n BCx - NGTD\n .\n UCx- NGTD\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n .H/O CONSTIPATION (OBSTIPATION, FOS)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), OTHER\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n .H/O DEPRESSION\n PNEUMONIA, ASPIRATION\n .H/O AORTIC ANEURYSM, THORACIC (TAA)\n 83 y/o M with PMhx of CVA, Recurrent Aspiration and UTIs who presented\n with fever, tachypnea and suspected aspiration now with CT abd\n concerning for cholecystitis.\n .\n # Fever/Leukocytosis: Improving. Pt afebrile with decreasing white\n count. be due to acute cholecystitis and/or aspiration pneumonia\n and/or UTI.\n - f/u urine, blood cx\n - continue empiric Vanc/Zosyn, Flagyl\n - repeat CXR in am\n - bolus IVF prn\n - goal UOP>30cc/hr\n - trend lactate, CBC, LFTs\n - aggressive pulm toilet\n .\n # Obstructive cholestasis/cholecystitis: HIDA suggests acute\n cholecystitis. No surgical intervention at this time. No need for\n percutaneous cholecystostomy.\n - trend LFTs, fractionate bili\n - follow abd exam\n -continue antibiotics for acute cholecystitis\n .\n # Hypoxia: resolving. Most likely due to aspiration pneumonia\n - cover empirically with Vanc/Zosyn\n - albuterol/atrovent nebs for wheezes\n - attempt pulm toilet\n - hold off on diuresis given recent hypotension\n - CXR in AM\n .\n # ARF: improving\n - bolus IVF\n - goal UOP of >30cc/hr\n - follow UCx\n - continue Zosyn for empiric coverage (h/o proteus/pseudomonas UTI)\n .\n # Fecal impaction: hold off on starting bowel regimen for now as pt\n having liquid stool around impaction\n - consider enema\n .\n # s/p PE on coumadin: INR continues to be supratherapeutic at 4.3.\n Received Vitamin K and FFP for possible IR procedure.\n - hold coumadin for now, trend coags\n .\n # s/p CVA: pt with \"locked in\" syndrome maintained on Diazepam for\n contractures.\n - continue diazepam 2mg PO daily\n .\n # FEN: NPO given possible aspiration (hold TF)\n - IVF boluses PRN and replete electrolytes aggressively\n - t/b with surgery re: nutrition\n ICU Care\n Nutrition: NPO for possible aspiration\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 05:19 PM\n Prophylaxis:\n DVT: p-boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: wife\n status: DNR/DNI\n Disposition: call out to floor\n" }, { "category": "Physician ", "chartdate": "2146-06-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 383859, "text": "Chief Complaint: Cholecystitis, coagulopathy\n HPI:\n HIDA scan consistent with acute cholecystitis. WBC down slightly,\n afebrile. LFT's improving.\n 24 Hour Events:\n NUCLEAR MEDICINE - At 02:00 PM\n History obtained from Medical records\n Patient unable to provide history: s/p stroke\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 12:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:26 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:35 PM\n Famotidine (Pepcid) - 08:50 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:48 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.9\nC (98.5\n HR: 62 (62 - 145) bpm\n BP: 106/50(64) {96/43(55) - 124/71(78)} mmHg\n RR: 20 (16 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.6 kg (admission): 82.4 kg\n Total In:\n 5,687 mL\n 956 mL\n PO:\n TF:\n IVF:\n 5,250 mL\n 776 mL\n Blood products:\n 257 mL\n Total out:\n 3,065 mL\n 1,335 mL\n Urine:\n 2,590 mL\n 1,335 mL\n NG:\n 475 mL\n Stool:\n Drains:\n Balance:\n 2,622 mL\n -379 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, left gaze preference\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: No(t) Normal, Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , No(t) Bronchial: , Wheezes : diffuse expiratory,\n Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese, Diminshed bowel sounds\n Extremities: Right: Trace edema, Left: Trace, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, No(t) Oriented (to): , Movement: Not assessed,\n No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 160 K/uL\n 123 mg/dL\n 1.5 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 110 mEq/L\n 142 mEq/L\n 28.3 %\n 22.3 K/uL\n [image002.jpg]\n 11:42 PM\n 12:31 AM\n 04:49 AM\n 04:28 PM\n 10:53 PM\n 05:04 AM\n WBC\n 28.6\n 26.3\n 25.5\n 22.3\n Hct\n 32.6\n 30.7\n 26.9\n 28.1\n 28.3\n Plt\n 166\n 156\n 155\n 160\n Cr\n 1.9\n 1.7\n 1.6\n 1.5\n TropT\n 0.03\n 0.02\n 0.01\n TCO2\n 21\n Glucose\n 123\n 107\n 128\n 123\n Other labs: PT / PTT / INR:41.1/54.6/4.3, CK / CKMB /\n Troponin-T:400/9/0.01, ALT / AST:24/43, Alk Phos / T Bili:50/0.9,\n Amylase / Lipase:37/11, Differential-Neuts:94.3 %, Lymph:1.3 %,\n Mono:3.2 %, Eos:0.1 %, D-dimer:962 ng/mL, Fibrinogen:736 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:2.6 g/dL, LDH:177 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n .H/O CONSTIPATION (OBSTIPATION, FOS)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), OTHER\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n .H/O DEPRESSION\n PNEUMONIA, ASPIRATION\n .H/O AORTIC ANEURYSM, THORACIC (TAA)\n CHOLECYSTITIS\n ===================\n Patient's numbers improving with antibiotics. Plan is to continue to\n treat cholecystitis medically. No evidence of sepsis. Afebrile. Plan to\n place PIC to allow D/C of femoral line.\n Creat slightly improved.\n Nebs for wheezing.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Patient with prolonged INR)\n Stress ulcer: H2 blocker\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2146-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383653, "text": "This 83 yr old man comes in through the EW w/probable aspiration PNA,\n possible cholecystitis, UTI, probable C-diff infection. PMH: multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal\n resident of Nursing Home.\n Pneumonia, aspiration\n Assessment:\n Received patient on nonrebreather w/O2 sats 96-100%\n Action:\n Placed patient on high flow neb @ % O2.\n Response:\n Plan:\n .H/O constipation (Obstipation, FOS)? Fecal impaction\n Assessment:\n CT showed fecal impaction w/no bowel obstruction. L femoral CVL\n placed for IV access.\n Action:\n Fecal collection bag placed over rectum as patient is constantly oozing\n stool (around impaction). Stool sent for C-diff.\n Response:\n L femoral kept clean.\n Plan:\n Patient needs line placed elsewhere.\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps)\n Action:\n Patient wearing waffle boots. Patient turned q 2 hrs.\n Response:\n Has vascular sores on R foot, otherwise skin is intact. Dressing last\n changed @ nursing home on . Cleaned w/NS & placed adaptic & kerlix\n to wounds. Will change R foot drsg .\n Plan:\n Continue skin care. Consider kinair bed.\n Atrial fibrillation (Afib)\n Assessment:\n HR: 80s-120\ns Afib BP 99-110\n Action:\n Coumadin held for INR 5.0. Lopressor held for low BP requiring 500cc\n LR bolus @ 0030.\n Response:\n Plan:\n Continue to monitor HR.\n" }, { "category": "Respiratory ", "chartdate": "2146-06-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 383664, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Nasotrachial Suction / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt seen for evalution for resp care. Pt on HiFlo as per\n Metavision. Lung sounds rhonchi dim R base suct mod th pale yellow\n sput; lung sounds ess clear but dim R base after suct; no wheezing\n noted. Cont HiFlo; pulmonary toilet; med nebs PRN.\n" }, { "category": "Physician ", "chartdate": "2146-06-28 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 383680, "text": "Chief Complaint: fever, obstructive cholestasis and ARF\n HPI:\n 83 y/o M with PMHx of CVA and resultant \"locked in\" syndrome, recurrent\n aspiration PNA and UTIs who presented with fever, tachypnea, abd\n distension and suspected aspiration event. Of note, pt is aphasic at\n baseline and unable to provide history. Per OMR, he had a new PEG tube\n placed on at . Per wife, the called and told her\n about his acute SOB and she asked them to send him into the ED for\n evaluation.\n .\n In the ED, initial VS were: T 101.2 BP 79/42 HR 109 RR 32 Sats 87% on\n RA which came up to 100% on a NRB. Pt received a total of 4L IVF,\n cipro 400mg IV, flagyl 500mg IV, Cefepime 2grams and Vanc 1gram. He\n had a left femoral placed and CXR revealed low lung volumes with\n possible right lower lobe infiltrate. He had a distended abd with\n mildly abnormal LFTs and thus, he underwent a CT abdomen which showed\n bilateral lower lobe infiltrates and distended GB with pericholecystic\n fluid concerning for acute cholecystitis. Surgery was consulted and\n recommended RUQ ultrasound which was not interpretable Surgery\n recommended admission to for MRCP to better evaluate for\n cholecystitis.\n .\n Review of sytems: unable to obtain\n .\n Patient admitted from: ER\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:00 AM\n Metronidazole - 03:04 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Senna 8.6 mg Cap\n Prilosec OTC 20 mg Tab daily\n Acetaminophen 325 mg Tab 2 Tablet(s) twice a day via jtube\n Potassium Chloride SR 20 mEq via G-tube once daily\n Baclofen 10 mg Tab 1 Tablet(s) QID via g-tube\n Coumadin 1 mg Tab\n Teargen 1.4 % Eye Drops gtts. ou four times a day\n Metoprolol SR 12.5 mg 24 hr twice a day give via j-tube\n Past medical history:\n Family history:\n Social History:\n CVA with \"locked in\" syndrome\n H/o PE on coumadin\n Dementia\n Depression\n Recurrent UTI\n s/p G-tube placement for recurrent aspiration\n Recurrent skin ulcer\n Atypical psychosis\n Thoracic aortic aneurysm\n h/o Recurrent UTIs including proteus\n non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt lives in , aphasic at baseline and dependant\n for all ADLs\n Flowsheet Data as of 04:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 90 (82 - 96) bpm\n BP: 116/47(65) {100/46(60) - 118/61(75)} mmHg\n RR: 22 (21 - 24) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,000 mL\n 1,263 mL\n PO:\n TF:\n IVF:\n 1,263 mL\n Blood products:\n Total out:\n 450 mL\n 360 mL\n Urine:\n 100 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,550 mL\n 906 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: 7.36/35/94./21/-4\n PaO2 / FiO2: 94\n Physical Examination\n T: 95.7 BP: 118/72 P: 90 R: 23 Sats 100% on NRB\n General: eyes open, grimaces to exam, no response to verbal stim\n HEENT: Sclera anicteric, pupils reactive\n Neck: supple, unable to assess JVP\n Lungs: audible upper airway secretions with rhonchi, difficult to\n appreciate any wheezes or rales, dysynchronous abd breathing\n CV: RRR, unable to appreciate murmurs through upper airway sounds\n Abdomen: mildly distended, no bowel sounds audible, grimaces to deep\n palpation, unable to assess rebound/guarding\n GU: foley in place\n Ext: warm, 1+ pulses, no cyanosis or edema, erosion and lateral\n deviation over MTP joint, no erythema or active drainage.\n Labs / Radiology\n 166 K/uL\n 11.3 g/dL\n 123 mg/dL\n 1.9 mg/dL\n 44 mg/dL\n 21 mEq/L\n 101 mEq/L\n 3.2 mEq/L\n 134 mEq/L\n 32.6 %\n 28.6 K/uL\n [image002.jpg]\n \n 2:33 A8/3/ 11:42 PM\n \n 10:20 P8/4/ 12:31 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 28.6\n Hct\n 32.6\n Plt\n 166\n Cr\n 1.9\n TropT\n 0.03\n TC02\n 21\n Glucose\n 123\n Other labs: PT / PTT / INR:46.1/73.5/5.0, CK / CKMB /\n Troponin-T:768/16/0.03, ALT / AST:19/47, Alk Phos / T Bili:52/1.1,\n D-dimer:962 ng/mL, Fibrinogen:736 mg/dL, Lactic Acid:1.8 mmol/L,\n LDH:229 IU/L, Ca++:6.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.9 mg/dL\n ABG on arrival to ICU 7.36/35/94 Lactate 1.9\n .\n Micro: blood & urine Cx pending\n .\n Images:\n CT Abd : Prelim gallstone in distended GB with peri-GB fluid\n concerning for cholecystitis, can be further evaluated with\n ultrasound. fecal impaction. no bowel obstruction. no free air. no\n abscess. stable calcified aortic thrombus. bibasilar consolidation\n concerning for PNA.\n .\n RUQ u/s prelim : very limited study due to overlying bowel gas\n and inability to reposition patient. gallstones in the gallbladder.\n minimal wall thicking of 4mm. trace equivocal fluid around the GB. the\n CBD could not be identified.\n .\n CXR portable : low lung volumes, right lower lobe infiltrate vs\n atelectasis.\n .\n EKG: sinus tachycardia without acute ST-T wave changes\n Assessment and Plan\n 83 y/o M with PMhx of CVA, Recurrent Aspiration and UTIs who presented\n with fever, tachypnea and suspected aspiration now with CT abd\n concerning for cholecystitis.\n .\n # Fever/Leukocytosis: Etiology unclear and multiple possible sources,\n loose stools and impressive leukocytosis makes Cdiff a possible source,\n h/o recurrent aspiration PNA with infiltrates and hypoxia suggests a\n possible component of aspiration PNA or pneumonitis. Initial UA\n positive for UTI and currently awaiting culture data. Additional\n concern for cholecystitis although Tbili only mildly elevated and alk\n phos was normal.\n - f/u urine, blood, sputum Cx if possible\n - continue empiric Vanc/Zosyn, Flagyl\n - send stool for Cdiff\n - repeat CXR in am\n - bolus IVF prn\n - goal UOP>30cc/hr\n - f/ recs, consider MRCP in am\n - f/u final read on CT abd and RUQ u/s\n - trend lactate, CBC, LFTs\n - aggressive pulm toilet\n - t/b with family regarding goals\n .\n # Hypoxia: Pt with h/o recurrent aspiration, now with possible right\n lower lobe infiltrate and bilateral lower lobe consolidation on CT abd\n (lung cuts). Pt unable to give h/o cough but with large A-A gradient\n and diffuse audible secretions. Possible additional component of fluid\n overload though difficult to interpret lung exam. Pt is unable to\n clear secretions and protect airway, there was a possible aspiration\n event in the NH prior to transfer to ED.\n - cover empirically with Vanc/Zosyn\n - send urine/blood and sputum Cx if possible\n - albuterol/atrovent nebs\n - attempt pulm toilet\n - hold off on diuresis given recent hypotension\n - f/u CXR in am\n .\n # ARF: Pt with acute renal failure likely due to dehydration and\n hypoperfusion. Pt may have component of ATN given hypotension though\n making good urine and creatinine trending down with IVF, will continue\n to trend UOP with boluses. Pt with h/o recurrent UTI and stones though\n no clear evidence of obstruction of CT abd\n - bolus IVF\n - goal UOP of >30cc/hr\n - follow UA and Cultures\n - continue Zosyn for empiric coverage (h/o proteus/pseudomonas UTI)\n - trend creatinine\n .\n # Obstructive cholestasis/cholecystitis: Pt with difficult abd exam,\n decreased bowel sounds and grimaces to exam. CT abd suggestive of\n cholecystitis although Tbili trending down\n - trend LFTs, fractionate bili\n - get MRCP per recs\n - serial abd exams\n .\n # Fecal impaction: hold off on starting bowel regimen for now as pt\n having liquid stool around impaction\n - send for Cdiff\n - consider enema in am\n .\n # s/p PE on coumadin: INR supratherapeutic at 5.0\n - hold coumadin for now, trend coags\n .\n # s/p CVA: pt with \"locked in\" syndrome maintained on Diazepam for\n contractures?\n - hold diazepam for now given recent hypotension\n .\n # FEN: NPO given possible aspiration (hold TF)\n - IVF boluses prn and replete electrolytes aggressively\n .\n # Prophylaxis: INR of 5 and Famotidine\n .\n # Access: Left femoral , likely need to be replaced in am\n .\n # CODE: DNR/DNI confirmed with HCP/Wife \n .\n # Communication: (wife) phone \n .\n # Disposition: for now\n ICU Care\n Nutrition: NPO for now\n Lines:\n Multi Lumen - 11:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n Communication:\n Code status: DNR / DNI\n Disposition: ICU\n ------ Protected Section ------\n I have seen and examined the patient with the resident and agree\n substantially with the assessment and plan as described above with the\n following exceptions/modifications:\n 83 year old male with dementia, CVA with locked in syndrome,\n contractures at baseline who presents with fever/hypotension and\n presumed septic shock. Etiologies as described above include potential\n cholecystitis, pneumonia, cholangitis.\n T 35.4 P 94 BP 112/50 Sat: 100% on high flow oxygen\n General: unresponsive and in respiratory distress. He appears very\n ill.\n CTA: coarse BS\n Heart: S1 S2 reg\n Abd: soft, NT\n A/P and Discussion: Given the underlying baseline status\n (dementia/locked-in with multiple medical problems described in\n resident note above) combined with sepsis and respiratory failure, I\n believe that the prognosis is dismal. The patient is currently DNR/DNI\n and given the above, comfort care would appear to be the most\n appropriate clinical pathway. We will be contacting the patient\ns wife\n for further discussion. In the meantime, will provide broad-spectrum\n antibiotic coverage for infection and monitor.\n ------ Protected Section Addendum Entered By: , MD\n on: 07:16 ------\n" }, { "category": "Physician ", "chartdate": "2146-06-28 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 383656, "text": "Chief Complaint: fever, obstructive cholestasis and ARF\n HPI:\n 83 y/o M with PMHx of CVA and resultant \"locked in\" syndrome, recurrent\n aspiration PNA and UTIs who presented with fever, tachypnea, abd\n distension and suspected aspiration event. Of note, pt is aphasic at\n baseline and unable to provide history. Per OMR, he had a new PEG tube\n placed on at . Per wife, the called and told her\n about his acute SOB and she asked them to send him into the ED for\n evaluation.\n .\n In the ED, initial VS were: T 101.2 BP 79/42 HR 109 RR 32 Sats 87% on\n RA which came up to 100% on a NRB. Pt received a total of 4L IVF,\n cipro 400mg IV, flagyl 500mg IV, Cefepime 2grams and Vanc 1gram. He\n had a left femoral placed and CXR revealed low lung volumes with\n possible right lower lobe infiltrate. He had a distended abd with\n mildly abnormal LFTs and thus, he underwent a CT abdomen which showed\n bilateral lower lobe infiltrates and distended GB with pericholecystic\n fluid concerning for acute cholecystitis. Surgery was consulted and\n recommended RUQ ultrasound which was not interpretable Surgery\n recommended admission to for MRCP to better evaluate for\n cholecystitis.\n .\n Review of sytems: unable to obtain\n .\n Patient admitted from: ER\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:00 AM\n Metronidazole - 03:04 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Senna 8.6 mg Cap\n Prilosec OTC 20 mg Tab daily\n Acetaminophen 325 mg Tab 2 Tablet(s) twice a day via jtube\n Potassium Chloride SR 20 mEq via G-tube once daily\n Baclofen 10 mg Tab 1 Tablet(s) QID via g-tube\n Coumadin 1 mg Tab\n Teargen 1.4 % Eye Drops gtts. ou four times a day\n Metoprolol SR 12.5 mg 24 hr twice a day give via j-tube\n Past medical history:\n Family history:\n Social History:\n CVA with \"locked in\" syndrome\n H/o PE on coumadin\n Dementia\n Depression\n Recurrent UTI\n s/p G-tube placement for recurrent aspiration\n Recurrent skin ulcer\n Atypical psychosis\n Thoracic aortic aneurysm\n h/o Recurrent UTIs including proteus\n non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt lives in , aphasic at baseline and dependant\n for all ADLs\n Flowsheet Data as of 04:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.4\nC (95.7\n Tcurrent: 35.4\nC (95.7\n HR: 90 (82 - 96) bpm\n BP: 116/47(65) {100/46(60) - 118/61(75)} mmHg\n RR: 22 (21 - 24) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,000 mL\n 1,263 mL\n PO:\n TF:\n IVF:\n 1,263 mL\n Blood products:\n Total out:\n 450 mL\n 360 mL\n Urine:\n 100 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,550 mL\n 906 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: 7.36/35/94./21/-4\n PaO2 / FiO2: 94\n Physical Examination\n T: 95.7 BP: 118/72 P: 90 R: 23 Sats 100% on NRB\n General: eyes open, grimaces to exam, no response to verbal stim\n HEENT: Sclera anicteric, pupils reactive\n Neck: supple, unable to assess JVP\n Lungs: audible upper airway secretions with rhonchi, difficult to\n appreciate any wheezes or rales, dysynchronous abd breathing\n CV: RRR, unable to appreciate murmurs through upper airway sounds\n Abdomen: mildly distended, no bowel sounds audible, grimaces to deep\n palpation, unable to assess rebound/guarding\n GU: foley in place\n Ext: warm, 1+ pulses, no cyanosis or edema, erosion and lateral\n deviation over MTP joint, no erythema or active drainage.\n Labs / Radiology\n 166 K/uL\n 11.3 g/dL\n 123 mg/dL\n 1.9 mg/dL\n 44 mg/dL\n 21 mEq/L\n 101 mEq/L\n 3.2 mEq/L\n 134 mEq/L\n 32.6 %\n 28.6 K/uL\n [image002.jpg]\n \n 2:33 A8/3/ 11:42 PM\n \n 10:20 P8/4/ 12:31 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 28.6\n Hct\n 32.6\n Plt\n 166\n Cr\n 1.9\n TropT\n 0.03\n TC02\n 21\n Glucose\n 123\n Other labs: PT / PTT / INR:46.1/73.5/5.0, CK / CKMB /\n Troponin-T:768/16/0.03, ALT / AST:19/47, Alk Phos / T Bili:52/1.1,\n D-dimer:962 ng/mL, Fibrinogen:736 mg/dL, Lactic Acid:1.8 mmol/L,\n LDH:229 IU/L, Ca++:6.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.9 mg/dL\n ABG on arrival to ICU 7.36/35/94 Lactate 1.9\n .\n Micro: blood & urine Cx pending\n .\n Images:\n CT Abd : Prelim gallstone in distended GB with peri-GB fluid\n concerning for cholecystitis, can be further evaluated with\n ultrasound. fecal impaction. no bowel obstruction. no free air. no\n abscess. stable calcified aortic thrombus. bibasilar consolidation\n concerning for PNA.\n .\n RUQ u/s prelim : very limited study due to overlying bowel gas\n and inability to reposition patient. gallstones in the gallbladder.\n minimal wall thicking of 4mm. trace equivocal fluid around the GB. the\n CBD could not be identified.\n .\n CXR portable : low lung volumes, right lower lobe infiltrate vs\n atelectasis.\n .\n EKG: sinus tachycardia without acute ST-T wave changes\n Assessment and Plan\n 83 y/o M with PMhx of CVA, Recurrent Aspiration and UTIs who presented\n with fever, tachypnea and suspected aspiration now with CT abd\n concerning for cholecystitis.\n .\n # Fever/Leukocytosis: Etiology unclear and multiple possible sources,\n loose stools and impressive leukocytosis makes Cdiff a possible source,\n h/o recurrent aspiration PNA with infiltrates and hypoxia suggests a\n possible component of aspiration PNA or pneumonitis. Initial UA\n positive for UTI and currently awaiting culture data. Additional\n concern for cholecystitis although Tbili only mildly elevated and alk\n phos was normal.\n - f/u urine, blood, sputum Cx if possible\n - continue empiric Vanc/Zosyn, Flagyl\n - send stool for Cdiff\n - repeat CXR in am\n - bolus IVF prn\n - goal UOP>30cc/hr\n - f/ recs, consider MRCP in am\n - f/u final read on CT abd and RUQ u/s\n - trend lactate, CBC, LFTs\n - aggressive pulm toilet\n - t/b with family regarding goals\n .\n # Hypoxia: Pt with h/o recurrent aspiration, now with possible right\n lower lobe infiltrate and bilateral lower lobe consolidation on CT abd\n (lung cuts). Pt unable to give h/o cough but with large A-A gradient\n and diffuse audible secretions. Possible additional component of fluid\n overload though difficult to interpret lung exam. Pt is unable to\n clear secretions and protect airway, there was a possible aspiration\n event in the NH prior to transfer to ED.\n - cover empirically with Vanc/Zosyn\n - send urine/blood and sputum Cx if possible\n - albuterol/atrovent nebs\n - attempt pulm toilet\n - hold off on diuresis given recent hypotension\n - f/u CXR in am\n .\n # ARF: Pt with acute renal failure likely due to dehydration and\n hypoperfusion. Pt may have component of ATN given hypotension though\n making good urine and creatinine trending down with IVF, will continue\n to trend UOP with boluses. Pt with h/o recurrent UTI and stones though\n no clear evidence of obstruction of CT abd\n - bolus IVF\n - goal UOP of >30cc/hr\n - follow UA and Cultures\n - continue Zosyn for empiric coverage (h/o proteus/pseudomonas UTI)\n - trend creatinine\n .\n # Obstructive cholestasis/cholecystitis: Pt with difficult abd exam,\n decreased bowel sounds and grimaces to exam. CT abd suggestive of\n cholecystitis although Tbili trending down\n - trend LFTs, fractionate bili\n - get MRCP per recs\n - serial abd exams\n .\n # Fecal impaction: hold off on starting bowel regimen for now as pt\n having liquid stool around impaction\n - send for Cdiff\n - consider enema in am\n .\n # s/p PE on coumadin: INR supratherapeutic at 5.0\n - hold coumadin for now, trend coags\n .\n # s/p CVA: pt with \"locked in\" syndrome maintained on Diazepam for\n contractures?\n - hold diazepam for now given recent hypotension\n .\n # FEN: NPO given possible aspiration (hold TF)\n - IVF boluses prn and replete electrolytes aggressively\n .\n # Prophylaxis: INR of 5 and Famotidine\n .\n # Access: Left femoral , likely need to be replaced in am\n .\n # CODE: DNR/DNI confirmed with HCP/Wife \n .\n # Communication: (wife) phone \n .\n # Disposition: for now\n ICU Care\n Nutrition: NPO for now\n Lines:\n Multi Lumen - 11:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n Communication:\n Code status: DNR / DNI\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2146-06-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 383706, "text": "Chief Complaint: Hypotension, Aspiration pneumonia, fever, abnormal\n LFTs\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Given 4 liters of IV fluid since admission with improvement in blood\n pressure. Temp has been down since admission to ICU. Has required O2\n by mask to sustain acceptable saturation.\n Creat improving with fluids. Metabolic acidosis persists.\n 24 Hour Events:\n MULTI LUMEN - START 11:30 PM\n History obtained from Medical records\n Patient unable to provide history: Aphasia\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:00 AM\n Metronidazole - 03:04 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Pepcid, vanco, flagyl\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 106 (82 - 106) bpm\n BP: 112/50(64) {100/43(55) - 118/61(75)} mmHg\n RR: 28 (21 - 28) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,000 mL\n 1,791 mL\n PO:\n TF:\n IVF:\n 1,791 mL\n Blood products:\n Total out:\n 450 mL\n 810 mL\n Urine:\n 100 mL\n 735 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 3,550 mL\n 981 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 96%\n ABG: 7.36/35/94./19/-4\n PaO2 / FiO2: 235\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, Left gaze preference\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: No(t) Normal, Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic), Heart sounds largely obscured by breath sounds\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: Diffuse\n upper airway rhonchi primarily on exhalation)\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)\n Distended, Tender: Equivocal RUQ, Obese\n Extremities: Right: Trace edema, Left: Trace, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, No(t) Oriented (to): , Movement: No spontaneous\n movement, No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 156 K/uL\n 107 mg/dL\n 1.7 mg/dL\n 19 mEq/L\n 3.4 mEq/L\n 44 mg/dL\n 103 mEq/L\n 135 mEq/L\n 30.7 %\n 26.3 K/uL\n [image002.jpg]\n 11:42 PM\n 12:31 AM\n 04:49 AM\n WBC\n 28.6\n 26.3\n Hct\n 32.6\n 30.7\n Plt\n 166\n 156\n Cr\n 1.9\n 1.7\n TropT\n 0.03\n 0.02\n TCO2\n 21\n Glucose\n 123\n 107\n Other labs: PT / PTT / INR:49.3/38.0/5.4, CK / CKMB /\n Troponin-T:771/16/0.02, ALT / AST:20/49, Alk Phos / T Bili:49/1.1,\n Amylase / Lipase:37/11, D-dimer:962 ng/mL, Fibrinogen:736 mg/dL, Lactic\n Acid:2.5 mmol/L, LDH:229 IU/L, Ca++:6.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.6\n mg/dL\n Fluid analysis / Other labs: C diff: negative\n UA: + WBCs\n Imaging: CXR: low lung volumes. Infiltrate along right heart border\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n .H/O CONSTIPATION (OBSTIPATION, FOS)\n .H/O CVA (STROKE, CEREBRAL INFARCTION), OTHER\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n .H/O DEPRESSION\n PNEUMONIA, ASPIRATION\n .H/O AORTIC ANEURYSM, THORACIC (TAA)\n ANEMIA\n ACUTE RENAL FAILURE\n METABOLIC ACIDOSIS\n HYPOTENSION\n HYPOCALCEMIA\n Patient with fever and leukocytosis of unclear etiology. Evidence on\n CXR of Right basilar infiltrate and patient with large secretions in\n posterior pharynx putting him at risk for aspiration. Oxygenation\n improved this AM; mask removed and O2 sats in mid 90s. LFTs abnormal\n with evidence on CT of dilated gall bladder. Physical exam is\n equivocal. Will obtain HIDA scan.\n Hypotension likely related to intravascular volume depletion and low\n SVR with fever and infection. BP improved this AM. Urine output good.\n Creat elevated but improved from adimission. have had severe\n pre-renal state with component of ATN. Continue to support with fluids\n to sustain good urine output > 40 cc hr.\n Metabolic acidosis initially a combination of lactic acidosis and\n uremia. Mild anion gap persists. Continue to support hemodynamics.\n Hct mildly reduced. No evidence of bleedking; value near baseline.\n Monitor stool guiaic.\n INR elevated on coumadin, which is being held.\n Serum calcium low; albumin being checked, calcium being repleted.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 11:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 383692, "text": "This 83 yr old man comes in through the EW w/probable aspiration PNA,\n possible cholecystitis, UTI, probable C-diff infection. PMH: multiple\n CVA\ns w/\nlocked in\n syndrome, dementia, depression, aspiration PNA,\n atypical psychosis, PE, thoracic aortic aneurysm. He is a nonverbal\n resident of Nursing Home.\n Pneumonia, aspiration\n Assessment:\n Received patient on nonrebreather w/O2 sats 96-100%\n Action:\n Placed patient on high flow neb @ 80-40 % O2. RT suctioned patient\n nasotracheally for moderate amount of thick yellow secretions.\n Response:\n Patient had O2 sats of 96-98% on 40% high flow neb\n Plan:\n Continue to titrate O2 down as tolerated.\n .H/O constipation (Obstipation, FOS)/ Fecal impaction\n Assessment:\n CT showed fecal impaction w/no bowel obstruction. L femoral CVL\n placed for IV access in EW.\n Action:\n Fecal collection bag placed over rectum as patient is constantly oozing\n stool (around impaction). Stool sent for C-diff.\n Response:\n L femoral CVL kept clean.\n Plan:\n Patient needs line placed elsewhere before fecal impaction is treated\n w/enemas etc.\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Patient is stiff, w/legs & arms extended. Jaw clenched preventing\n access into mouth (for suctioning, mouth care, po temps).\n Action:\n Patient wearing waffle boots. Patient turned q 2 hrs.\n Response:\n Has vascular sores on R foot, otherwise skin is intact. Dressing last\n changed @ nursing home on . Cleaned w/NS & placed adaptic & kerlix\n to wounds. Will change R foot drsg .\n Plan:\n Continue skin care. Consider kinair bed.\n Atrial fibrillation (Afib)\n Assessment:\n HR: 80s-120\ns Afib BP 99-110\n Action:\n Coumadin held for INR 5.0-5.4. Lopressor held for low BP requiring\n 500cc LR bolus @ 0030.\n Response:\n Plan:\n Continue to monitor HR.\n" }, { "category": "ECG", "chartdate": "2146-06-27 00:00:00.000", "description": "Report", "row_id": 141985, "text": "Sinus tachycardia. Possible left atrial abnormality. Consider inferior\nmyocardial infarction. Late R wave progression with early precordial Q waves.\nConsider anteroseptal myocardial infarction. ST-T wave abnormalities.\nSince the previous tracing of ventricular premature beats are no longer\nseen.\n\n" }, { "category": "Radiology", "chartdate": "2146-07-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1092412, "text": " 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute change\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with locked in syndrome, new fever, sob, tachypnea\n REASON FOR THIS EXAMINATION:\n eval for acute change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: New onset of fever and SOB.\n\n Increased opacification in the left base is seen, consistent with pneumonia in\n this region. Some opacification in the right base is also present, not\n significantly changed since the prior chest x-ray.\n\n IMPRESSION: Increasing left basal opacification consistent with pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2146-06-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1092100, "text": " 1:23 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Pt had a right sided picc line placed,47cm and needs tip con\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with UTI who needs picc line for IV antibiotics.\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed,47cm and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:29 PM\n 1. New right PICC line terminates in mid-to-lower SVC without complications.\n 2. New opacity in the right lung base and increased left lower lobe\n opacification likely represents aspiration and atelectasis.\n 3. Increased bilateral small pleural effusions, left greater than right.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old male patient with UTI and now new PICC line. Study to\n evaluate PICC line placement.\n\n TECHNIQUE: Single portable chest radiograph is compared to prior examination\n through at 5:43 a.m.\n\n FINDINGS: A new right PICC line terminates in the mid-to-lower SVC without\n complications. New hazy opacity is identified in the right lung base,\n suggestive of aspiration. In addition, the previously noted retrocardiac\n opacity is now worsened, completely obliterating the left hemidiaphragm, also\n containing air bronchograms. This appearance is consistent with consolidation\n or/and atelectasis. There is increase in bilateral small pleural effusions,\n left greater than right. The upper lungs are clear. There is no evidence of\n fluid overload or pneumothorax. Cardiomediastinal contour is stable.\n\n IMPRESSION:\n 1. New right PICC line terminates in mid-to-lower SVC without complication.\n 2. Increased retrocardiac opacity and new right lower lung opacities, likely\n represent aspiration.\n 3. Increased bilateral small pleural effusions, left greater than right.\n\n The above findings were discussed with Dr. at the time of this\n dictation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-06-27 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1091632, "text": " 2:08 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? obstruction / perf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with fever, dyspnea, distended abd, locked in syndrome\n REASON FOR THIS EXAMINATION:\n ? obstruction / perf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 83-year-old male with fever, dyspnea, and locked-in\n syndrome. With distended abdomen. Evaluate for obstruction or perforation.\n\n EXAMINATION: Single portable abdominal radiograph.\n\n COMPARISONS: Comparison to radiograph from .\n\n FINDINGS: This is a limited examination with lateral aspects of the abdomen\n and the upper abdomen not imaged. There is massive fecal impaction with\n distension of the rectum and sigmoid colon. There are associated prominent\n gaseously distended loops of large bowel. A gastrotomy tube is seen with tip\n projecting over the mid abdomen. There is stable appearance of heterotopic\n ossification about both the bilateral femoral necks. This single view is\n limited for the evaluation of free air.\n\n IMPRESSION: Extremely limited study with only lower abdomen imaged. Within\n these limitations, massively fecally impacted rectum and sigmoid colon.\n Recommend repeat radiographs post-disimpaction.\n\n" }, { "category": "Radiology", "chartdate": "2146-06-27 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1091634, "text": " 2:24 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction / perf / abscess\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with fever, abdominal pain, dyspnea\n REASON FOR THIS EXAMINATION:\n ? obstruction / perf / abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw MON 7:41 PM\n gallstone in distended GB with peri-GB fluid concerning for cholecystitis, can\n be further evaluated with ultrasound.\n\n fecal impaction. no bowel obstruction. no free air. no abscess. stable\n calcified aortic thrombus. bibasilar consolidation concerning for PNA.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: An 83-year-old man with fever and abdominal pain and dyspnea,\n evaluate for obstruction, perforation or abscess.\n\n CT ABDOMEN AND PELVIS: Helical imaging was performed from the lung bases to\n the pubic symphysis after oral contrast administration. IV contrast was not\n administered, secondary to elevated creatinine.\n\n COMPARISON: CT torso .\n\n CT ABDOMEN: The partially visualized lung bases demonstrate a small right\n pleural effusion with bibasilar atelectasis and/or consolidation. The\n partially visualized heart demonstrates coronary artery vascular\n calcifications. There is aneurysmal dilation of the abdominal aorta at the\n level of the diaphragmatic hiatus measuring 4.1 x 4.3 cm consistent with known\n region of calcified aortic thrombus which is stable, but not fully evaluated\n due to lack of intravenous contrast\n\n Lack of IV contrast limits solid intra-abdominal organ evaluation. Given\n these limitations, the spleen appears normal. There is diffuse enlargement of\n the medial and lateral limbs of the right adrenal gland which have a stable\n lobulated appearance. There is intermediate density poorly defined mass in\n the interpolar region of the left kidney (2A:26), seen previously but\n difficult to evaluated on the current study due to lack of intravenous\n contrast. This can be further followed-up on contrast enhanced CT or MRI.\n\n There are areas of coarse calcification along the left renal parenchyma, which\n may be vascular calcifications or nonobstructing calculi. In the right kidney\n are several coarse calcifications representing nonobstructive calculi which\n are stable (2A:32) measuring 9 mm. In the posterior aspect of the right kidney\n (2A:32) is slight enlargement, which corresponds to site of prior subcapsular\n hematoma, not well evaluated on this study.\n\n The liver parenchyma appears unremarkable. There are at least two gallstones\n within the gallbladder measuring 9 mm each. The gallbladder is distended and\n there is trace pericholecystic fluid (2A:7). The CBD is not well visualized on\n (Over)\n\n 2:24 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? obstruction / perf / abscess\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n this study. There is a hiatal hernia. The stomach appears unremarkable;\n however, there is a G to J-tube. Abdominal loops of small bowel appear\n unremarkable. There is no free air or free fluid in the abdomen. There is no\n significant retroperitoneal or mesenteric lymphadenopathy.\n\n CT PELVIS: There is a marked fecal loading distally with distention of the\n rectum. There is a Foley in the decompressed bladder. There is no free air or\n free fluid in the pelvis. There is no bowel obstruction. There is a left\n femoral approach venous catheter.\n\n BONE WINDOWS: There is prior trauma and fracture at the left lesser\n trochanter. There is scoliosis deformity of the spine with degenerative\n changes in the lower lumbar spine and along the right ischial tuberosity.\n\n IMPRESSION:\n 1. Distended gallbladder containing gallstones and pericholecystic fluid,\n cholecystitis is not excluded. Correlate with lab vlaues adn clinical\n suspicion for cholecystitis. If further imaging is required, consider HIDA\n scan. US is unlikely to add further diagnostic value.\n 2. Signifcant fecal loading, correlate for clinical evidence of fecal\n impaction.\n 3. Bibasilar areas of atelectasis and/or consolidation with small right\n pleural effusion.\n 4. Incompletely assessed region of intermediate density in the left kidney,\n if clinically warranted, could be further evaluated with MRI.\n 5. Non obstructive renal calculi.\n 6. Dilated aorta at the diaphragmatic hiatus is stable in size, but not fully\n evaluated given lack of intravenous contrast.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-06-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1092101, "text": ", M. MED 1:23 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Pt had a right sided picc line placed,47cm and needs tip con\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with UTI who needs picc line for IV antibiotics.\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed,47cm and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n PFI REPORT\n 1. New right PICC line terminates in mid-to-lower SVC without complications.\n 2. New opacity in the right lung base and increased left lower lobe\n opacification likely represents aspiration and atelectasis.\n 3. Increased bilateral small pleural effusions, left greater than right.\n\n" }, { "category": "Radiology", "chartdate": "2146-06-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1091859, "text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrate\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with locked in syndrome, fever, h/o aspirations\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:42 A.M., \n\n HISTORY: An 83-year-old man with locked in syndrome, fever and history of\n aspirations.\n\n IMPRESSION: AP chest compared to :\n\n Progressive consolidation at the right lung base could be due to either\n worsening pneumonia or atelectasis. Atelectasis at the base of the left lung\n is less severe but stable. Cardiac silhouette is hard to assess, because of\n adjacent pleural and parenchymal abnormalities. Pleural effusion is small, if\n any. The head and mandible obscure the lung apices particularly the left.\n No pneumothorax is evident along the imaged portions of pleural surfaces.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1091629, "text": " 2:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with fever, dyspnea, locked in syndrome\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 83-year-old male with fever and dyspnea and locked-\n in syndrome. Evaluate for pneumonia.\n\n EXAMINATION: Single frontal chest radiograph.\n\n COMPARISONS: Comparison to radiographs from ; CT .\n\n FINDINGS: Study is markedly limited due to low lung volumes and motion blur.\n There is bibasilar atelectasis. There is blurring of the left lung base\n limiting further evaluation. Upper lungs are well aerated. No evidence of\n pneumothorax. There are incompletely imaged portions of a mid abdominal\n catheter compatible with known G-tube. Cardiomediastinal silhouette is stable\n in appearance demonstrating ectasia of the descending thoracic aorta. A\n curvilinear calcification projecting over the left heart is stable and\n represents a calcified aneurysm as seen on prior CT. Visualized osseous\n structures are unchanged.\n\n IMPRESSION: Limited study, bibasilar atelectasis. Repeat study if needed with\n more optimized technique.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-07-02 00:00:00.000", "description": "L FOOT AP,LAT & OBL LEFT", "row_id": 1092411, "text": " 10:03 AM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: eval for e/o osteo\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with deep ulcer, probing to bone of medial 1st MTP. MRSA\n bacteremia, locked in syndrome - cannot move or interact verbally.\n REASON FOR THIS EXAMINATION:\n eval for e/o osteo\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Deep ulcer by first metatarsophalangeal joint. Evaluate\n for osteomyelitis.\n\n First metacarpophalangeal joint is not well demonstrated on either film.\n Considerable deformity of all the toes is present. No lytic areas are\n identified, but osteomyelitis cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-06-27 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1091690, "text": " 9:13 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval cholecystitis\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with hx ?chole on CT\n REASON FOR THIS EXAMINATION:\n eval cholecystitis\n ______________________________________________________________________________\n WET READ: JMGw MON 9:52 PM\n very limited study due to overlying bowel gas and inability to reposition\n patient. gallstones in the gallbladder. minimal wall thicking of 4mm. trace\n equivocal fluid around the GB. the CBD could not be identified.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old man with history of cholecystectomy on CT. Evaluate for\n cholecystitis.\n\n LIVER ULTRASOUND:\n\n COMPARISON: CT abdomen and pelvis , performed same day.\n\n FINDINGS: Study is extremely limited secondary to overlying bowel gas and\n inability to reposition patient for more optimal imaging. There are multiple\n hyperechoic stones seen within the gallbladder with posterior shadowing, also\n seen on prior CT. Limited views of the gallbladder wall demonstrated\n gallbladder wall measuring approximately 4 mm. There is trace pericholecystic\n fluid. The CBD could not be identified.\n\n IMPRESSION: Very limited ultrasound evaluation of the gallbladder\n demonstrating multiple stones and minimal wall thickening but trace\n pericholecystic fluid. If there remains clinical concern for cholecystitis,\n would recommend further evaluation with a nuclear medicine HIDA scan.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1091715, "text": " 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evaluate for evolving infiltrates\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with fever, leukocytosis and possible aspiration PNA\n REASON FOR THIS EXAMINATION:\n pls evaluate for evolving infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Possible aspiration pneumonia, evaluation for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the image quality is\n improved. There is unchanged elevation of the right hemidiaphragm, unchanged\n retrocardiac opacities that could correspond either to atelectasis or to\n aspiration. At the bases of the right lung, there is only minimal\n atelectasis, but no evidence of aspiration or pneumonia. The size of the\n cardiac silhouette is at the upper range of normal. No evidence of\n overhydration. No pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-07-02 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 1092458, "text": " 5:20 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: eval for dvt\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with RUE edema greater than L, PICC in R.\n REASON FOR THIS EXAMINATION:\n eval for dvt\n ______________________________________________________________________________\n WET READ: JKSd SAT 7:23 PM\n Extremely limited exam due to patient's inability to move arm and head. No\n thrombus seen in visualized veins and no thrombus along PICC followed up to\n axillary vein.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old man with right upper extremity edema greater than\n left. PICC in the right arm. Evaluate for DVT.\n\n COMPARISON: None.\n\n FINDINGS: Please note that this examination was extremely limited due to\n patient's inability to move his head or arms. Grayscale and color Doppler\n son were performed of the right upper extremity. The axillary vein and\n basilic veins were visualized and compressed and demonstrate normal flow and\n compression. The brachial veins were also visualized and demonstrated normal\n flow and compression. No intraluminal thrombus was seen. The PICC was seen\n from its insertion site to the axilla without evidence of thrombus. The\n cephalic veins could not be visualized.\n\n IMPRESSION: Extremely limited examination due to patient's inability to move\n arms or head. However, no definitive thrombus seen.\n\n" }, { "category": "Radiology", "chartdate": "2146-06-28 00:00:00.000", "description": "GALLBLADDER SCAN", "row_id": 1091745, "text": "GALLBLADDER SCAN Clip # \n Reason: 83 Y/O MAN WITH LOCKED IN SYNDROME, FEVER, POSSIBLE RUQ PAIN, EVAL FOR CHOLECYSTITIS\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 4.1 mCi Tc-m DISIDA ();\n 3.8 mCi Tc-99m DISIDA ();\n HISTORY: Leukocytosis, elevated bilirubin and abnormal CT scan and US. Known\n cholelithiasis.\n\n\n INTERPRETATION: Serial images over the abdomen show uptake of tracer into the\n hepatic parenchyma. The gallbladder remains enlarged projecting as a prominent\n photopenic defect over the liver and never fills with tracer both pre and post\n 2mg IV Morphine administration. Tracer activity noted in the small bowel at 10\n minutes.\n\n IMPRESSION:\n Acute cholecystitis\n\n D/w Dr. at 4pm.\n\n\n\n\n , M.D.\n , M.D. Approved: WED 4:36 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2146-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1092009, "text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrates\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with An 83-year-old man with locked in syndrome, fever and\n history of aspirations.\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Portable AP chest radiograph was compared to , .\n\n This study is extremely limited since the patient head is obscuring most of\n the left upper lung and part of the right apex. There is no significant\n change in bibasilar atelectasis. The patient might be in pulmonary edema,\n which is not clearly seen on the current examination. The pleural effusion is\n most likely present, bilateral. Aortic calcification and aneurysmatic\n dilatation is again partially imaged.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2115-09-23 00:00:00.000", "description": "Report", "row_id": 68565, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Shortness of breath.\nHeight: (in) 71\nWeight (lb): 170\nBSA (m2): 1.97 m2\nBP (mm Hg): 140/55\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 16:26\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size.\n2.Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is normal\n(LVEF>55%).\n3.Right ventricular chamber size and free wall motion are normal.\n4.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. 5.The mitral valve appears structurally\nnormal with trivial mitral regurgitation.\n6.There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 835400, "text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: gentleman with pna and hypoxia\n Admitting Diagnosis: COLITIS-GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with fever and rll pna\n\n REASON FOR THIS EXAMINATION:\n gentleman with pna and hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia and hypoxia, followup examination.\n\n FINDINGS: AP single view of the chest obtained with the patient in semi-\n upright position is analyzed in direct comparison with the next previous\n similar chest examination of . The heart size is unchanged\n without typical configurational abnormality.\n\n No pulmonary vascular congestion is present but the previously described\n bilateral basal parenchymal densities persist. Blunting of the pleural sinus\n and linear density along the right lateral wall are suggestive of a moderate\n degree bilateral pleural effusion. There is no pneumothorax. Direct\n comparison of the two studies with 24-hour interval suggests mild regression\n of the mostly basally located parenchymal infiltrates.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-09-21 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 835152, "text": " 12:47 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: rlq pain fever, vomiting- eval for appy\n Admitting Diagnosis: COLITIS-GASTROENTERITIS\n Field of view: 36 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with\n REASON FOR THIS EXAMINATION:\n rlq pain fever, vomiting- eval for appy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Right lower quadrant pain, with fever, query appendicitis.\n\n TECHNIQUE: CT scan of the abdomen and pelvis was performed with 5 mm\n collimation after the administration of oral and intraveous contrast. No\n priors.\n\n CT abdomen with contrast: The lung bases demonstrate small bilateral pleural\n effusions, as well as atelectasis at the right base. The liver is\n unremarkable in appearance. There is moderate ascites. The gallbladder,\n pancreas, adrenals and spleen are within normal limits. The kidneys contain\n multiple cysts bilaterally. The cysts range in size from 4 mm to 13 mm, and\n in total six cysts are identified. No solid renal lesions or evidence of\n hydronephrosis.\n\n CT pelvis with contrast: The appendix is normal. There is moderate fluid\n tracking into the pelvis. The terminal ileum is not completely distended,\n though there is the suggestion of mild wall thickening, which may be\n exaggerated secondary to incomplete distention. There is adenopathy within the\n pelvis and within the right lower quadrant of the abdomen.\n\n The colon demonstrates diffuse wall thickening, with areas of wall thickening\n measuring up to 4 mm. The degree of wall thickening is greatest in the recto-\n sigmoid colon, and to a lesser extent involves the transverse colon and\n descending colon. The ascending colon appears relatively unaffected.\n\n Urinary bladder, prostate, and seminal vesicles are within normal limits.\n\n Bone windows: Multiple bone islands are seen within the femurs and iliac\n bones. No suspicious bony lesions.\n\n Multiplanar reconstructions confirm the above findings.\n\n IMPRESSION:\n 1) Diffuse wall thickening involving the colon, particularly the rectosigmoid\n colon, with free fluid and adenopathy. The findings are concerning for a\n diffuse colitis, infectious or inflammatory.\n 2) Questionable thickening of the terminal ileum, which may represent\n terminal ileitis.\n 3) Normal appendix.\n (Over)\n\n 12:47 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: rlq pain fever, vomiting- eval for appy\n Admitting Diagnosis: COLITIS-GASTROENTERITIS\n Field of view: 36 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2115-09-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 835525, "text": " 8:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please re-evaluate pna\n Admitting Diagnosis: COLITIS-GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with pna.\n REASON FOR THIS EXAMINATION:\n please re-evaluate pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22 Y/O man with pneumonia.\n\n TECHNIQUE: Portable AP chest radiograph. Comparison is made with the\n previous chest radiograph dated .\n\n FINDINGS: The previously noted patchy consolidation in the right lower lobe\n has decreased compared to the previous study. The previously noted\n consolidation of the left lower lobe has also decreased compared to the\n previous study. Interstitial markings are slightly increased in the right\n lung, suggesting congestion. The heart is normal in size. There is no left\n pleural effusion.\n\n There is no suspicious abnormalities identified in the skeletal structures or\n in the upper abdomen.\n\n IMPRESSION: Decreased consolidation in bilateral lower lobes, suggesting\n improving pneumonia. Small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2115-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 835283, "text": " 8:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA getting a lot worse?\n Admitting Diagnosis: COLITIS-GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with fevers and colitis on CT, dropping O2sats - 93 on NRB\n REASON FOR THIS EXAMINATION:\n PNA getting a lot worse?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fevers, hypoxia. Evaluate for worsening pneumonia.\n\n PORTABLE AP CHEST: Comparison is made with study from . Cardiac\n size is borderline. There are worsening predominantly alveolar, but possibly\n interstitial opacities throughout both lungs, and worsening bilateral pleural\n effusions. The left effusion is new. Osseous structures are unchanged.\n\n IMPRESSION: Worsening bilateral lung opacities, may represent worsening\n fulminant pneumonia or early ARDS.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-09-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 835241, "text": " 4:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: COLITIS-GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with fevers and colitis on CT, with hypoxia on RA and crackles\n on exam\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 16:32.\n\n INDICATION: Fevers and colitis.\n\n COMPARISON: .\n\n FINDINGS: Patchy density is seen in the right lower lobe consistent with\n pneumonia. The pulmonary vessels are normal, the cardiac silhouette is normal\n in size and the left costophrenic sulcus is sharply delineated.\n\n IMPRESSION: Right lower lobe pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-09-26 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 835703, "text": " 2:12 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: ELEVATED LFT'S,ELEVATED PANCREATIC ENZYMES\n Admitting Diagnosis: COLITIS-GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with recent ileitis, diarrhea, pneumonia now with\n transaminitis, elevated pancreatic enzymes, amber urine.\n REASON FOR THIS EXAMINATION:\n liver abnormalities? kidney, spleen abml?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elevated LFTs in patient with iliitis.\n\n FINDINGS: Bilateral pleural effusions are present (right greater than left).\n The liver is normal in contour and echogenicity with no evidence of hepatic\n mass or biliary ductal dilatation. The portal vein is patent with flow in an\n appropriate direction. The common duct is not dilated. The gallbladder is\n normal in appearance with no evidence of gallstones. There is no evidence of\n free fluid within the abdomen. The right kidney measures 12.0 cm. The left\n kidney measures 11.6 cm. There is a 1.2 cm simple cyst within the upper pole\n of the left kidney. There is no evidence of renal mass, stone, or\n hydronephrosis. The spleen is not enlarged. The aorta is of normal caliber\n throughout.\n\n IMPRESSION: Bilateral pleural effusions (right greater than left). Otherwise\n normal abdominal ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2115-09-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 835117, "text": " 4:08 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with fever\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22 year old man with fever. Evaluate for pneumonia.\n\n PA AND LATERAL CHEST: Heart size, mediastinal contours, and pulmonary\n vasculature are normal. Lungs are clear. No pleural effusions. Bones are\n normal.\n\n IMPRESSION: Normal chest.\n\n" }, { "category": "Nursing/other", "chartdate": "2115-09-23 00:00:00.000", "description": "Report", "row_id": 1376347, "text": "Admission to CSRU\nD/A: VSS, tmax 99.5. Sats 88-89% on 6L via NC. Tachypnic and obvious diff breathing, using accessory muscles and labored breathing. Lungs clear with decreased right base. No cough. Diaphoretic. No c/o pain at time of admission. Pt c/o headache during upright positions, Tylenol given and placed supine. Neuro assessment unremarkable. MAE to command. PERRLA. Abd soft and nondistended with +BS. Diarrhea x1 mix with urine. Adv diet as tol. Labs sent. Blood cultures sent. Cont with IV ABX. Lasix given.\nR: throughout night. Toll all procedures and treatments well. Awaiting BM to send for stool specimen. Discussed plan with sx. Oxycodone ordered if headache continues. Responds to lasix. Family at bedside. Will cont to \n" }, { "category": "Nursing/other", "chartdate": "2115-09-24 00:00:00.000", "description": "Report", "row_id": 1376348, "text": "NEURO: ALERT AWAKE ORIENTED X3; C/O H/A EARLIER THIS AFTERNOON BELIEVED TO BE D/T LP-MEDICATED WITH APAP; NO COMPLAINTS SINCE 1900 OF H/A;\nRESP: LSC XCEPT DIM IN RLL; SATS 95-97 ON 6LPM; NO RESP DISTRESS NOTED WHEN OOB TO COMMODE TO MOVE BOWELS; STATES\"BREATHING MUCH BETTER\"\nCV: NSR-SB; NO ECTOPY- SBP IN 120'S; GOOD PULSES; GOOD UO; ECHO SHOWED NORMAL HEALTHY HEART\nGI/GU: BSX4 HYPERACTIVE; MEDICATED WITH ZOFRAN FOR C/O NAUSEA; ABD SOFT NON-TENDER; BMX1 LIQUID GREEN-BILE LOOKING STOOL; GUIAC NEG ABD CT SHOWED INTESTINAL THICKENING AND COLITIS;STOOL SENT TO LAB FOR MICRO; NEED ONE MORE STOOL SAMPLE IN PENDING LABS; UO RESPONED WELL TO LASIX GIVEN ON DAY SHIFT; 600CC; CONDOM CATH REMOVED PT TO VOID IN URINAL; URINE SAMPLE STILL NEEDED BY LAB\nID: FEVER HAS BROKEN; STILL NOTED TO BECOME VERY DIAPHORETIC AT TIMES; BCX1 DUE WITH AM LABS; STILL ON ABT LEVO DUE AT 0200; IV SITE QUESTIONABLE- STREAKING NOTED NEED TO BE CHANGED\n" }, { "category": "Nursing/other", "chartdate": "2115-09-24 00:00:00.000", "description": "Report", "row_id": 1376349, "text": "Admission note: to MICU\n\nPatient arrived at 0100, painfree, afebrile and with no SOB. Ws admitted from ER to floor on the 14th with Mental status changes, fever, and abdominal pain. LP negative to r/o for meningitis (had headache), CT scan showed thickening of Colon, infective vs. inflamatory colitis. has bacteremia. Patient developed SOB, hypoxia and hypoxemia and was transferred to CSRU for ? intubation. CXR showed RLL infiltrate/fluid and patient was given lasix 20mg with good effect. ? pnuemonia vs aggressive fluis rescusitation Avoided intubation and currently on 6L O2 on arrival to MICU. Allowed sips of water\nPatient very tired and frustrated with moving, light outs to let patient sleep. Currently on Flagyl, levo, subcut heparin.\n\n , RN\n" }, { "category": "Nursing/other", "chartdate": "2115-09-24 00:00:00.000", "description": "Report", "row_id": 1376350, "text": "Progress Note:\n\nPatient orient X 3. Afebrile but diaphoretic at times. Normotensive and in NSR/SB.\nHAs slept thru the night. Was weaning down O2 to 4L...doing well....on hourly check at 0400 patient had removed the NC, Sp02 94%, (goal >92%). He is currently on RA.\n\nWill draw BC and labs at 0600. Needs urine (has not voided) and stool for cultures as well.\n\nWill assess Peripheral IV for changing since it appear to track up arm on arrival...patient had refused it changed in CSRU.\n\n be called out today.\n\n , RN\n" } ]

[ { "category": "Radiology", "chartdate": "2174-05-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1014125, "text": " 10:36 AM\n CHEST (PA & LAT) Clip # \n Reason: one day after second thoracentesis this admission - interval\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52F ped struck moderate speed (~6 wks ago), p/w dyspnea on exertion and lg\n left-sided pleural effusion s/p left thoracentesis w/2.5L drainage by IP ()\n REASON FOR THIS EXAMINATION:\n one day after second thoracentesis this admission - interval study\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FROM \n\n HISTORY: Recent motor vehicle accident with large left pleural effusion.\n Complaining of dyspnea.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Previously severe left lung consolidation has improved. A smaller volume of\n consolidation remains in the right apex and perihilar right mid lung. Small\n bilateral pleural effusions are probably unchanged over the past several days.\n Heart size is normal. There is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1013828, "text": " 6:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman w/ L pleural effusion s/p L thoracentesis\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:03 A.M., \n\n HISTORY: Left thoracentesis.\n\n IMPRESSION: AP chest compared to :\n\n Consolidation in the left lung continues to expand, and there is new\n consolidation in the infrahilar right lung. There may also be an increase in\n left pleural effusion, difficult to separate from dense consolidation. There\n is no pneumothorax. Cardiac silhouette is partially obscured. Left seventh\n rib fracture noted. No pneumothorax. Findings are most unusual for\n post-thoracentesis pulmonary edema and suggest instead pulmonary hemorrhage or\n pneumonia.\n\n Dr. was paged at the time of this dictation to discuss the\n progression on chest radiographs since .\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-07 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1013798, "text": " 8:57 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PTX - patient tachy with increased o2 requirement\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman s/p Left sided pleural effusion evac. by IP thoracentesis\n REASON FOR THIS EXAMINATION:\n PTX - patient tachy with increased o2 requirement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:07 P.M. ON .\n\n HISTORY: Left pleural effusion. Tachycardia.\n\n IMPRESSION: AP chest compared to , 6:57 p.m.:\n\n There has been no increase in left pleural effusion but consolidation in the\n left mid and lower lung has increased substantially, an unusual pattern for\n first reexpansion pulmonary edema suggesting instead pulmonary hemorrhage.\n There is no pneumothorax. Right lung is clear and heart size is normal.\n Minimally displaced fracture of the left seventh rib is unchanged and may be a\n second fracture, of the left tenth rib laterally, chronicity indeterminate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-05-09 00:00:00.000", "description": "Report", "row_id": 1660856, "text": "TSICU NPN 2300-0700\nREVIEW OF SYSTEMS:\n\nNEURO: A&OX3, no neuro deficits noted. Toradol given PRN for pain.\n\nCV: NSR, HR 70-90's, no ectopy noted. SBP WNL. PIV X 2. Afebrile.\n\nRESP: 3L NC with SATS >96%. Right LS clear, Left upper lobe noted with crackles, decreased at bases. No respiratory distress noted.\n\nENDO: No coverage needed per RISS.\n\nGI: Abd soft, non-distended. Clear liquid diet, tolerating well.\n\nGU: Voiding clear yellow urine via bedpan.\n\nSKIN: Left thoracentesis site with puncture wound, healing well. Backside intact.\n\nSOCIAL: Mother and husband called last evening, pt spoke with both on phone.\n\nPLAN: ? bronch today. Transfer to floor.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-05-09 00:00:00.000", "description": "Report", "row_id": 1660857, "text": "0700-present\nTransfer note in chart see transfer note for full note\n" }, { "category": "Nursing/other", "chartdate": "2174-05-08 00:00:00.000", "description": "Report", "row_id": 1660854, "text": "admit note\n\n52 yr women with history of osteopenia, OCD, anxiety and multi trauma on , pt was a pedestrian struck. sustained multi right rib fx, left foot and ankle fx, right foot fx, left scapula fx, pelvic fx, T7-11 cv junction fx. had been d/c from rehab and was at home. re-admitted to with left plural effusion and dislocation T7 rib fx.d/c home with new pain med regime including ms contin and oxycodone. re-admitted to after 2-3 days increased orthopnea, dyspnea, and fever. pt found to have a worsening plural effusion and had a thoracentesis on , for 2.5 liters of fluid. post proceedure pt became febrile up to 104, sats down to mid 80's on 2l nc, and tachycardic. pt brought to T/SICU from CC6 for closer monitoring.\n\nneuro- pt alert and oriented. c/o left chest pain, toradol given with good effect.\n\ncv- HR ST 110 now down to 86 NSR. b/p wnl + peripheral pulses, p-boots and sq heparin.\n\nresp- pt placed on 10L NRB sats in mid to high 90's. RR 20's tol well. lung sounds clear on right crackles on left. CXR post proceedure on floor showed no pnumothorax.\n\nGI- npo abd soft NT.\n\nGU- refused cath. has not voided since admit to ICU. no IVF.\n\nskin- puncture site to left back from proccedure. wnl.\n\nendo- s/s coverage.\n\nID- temp 101 on arrival. down to 100. tylenol given on floor before transfer. WBC up to 13 from 6. 2 sets blood cx sent.\n\nsocial- husband notified of ICU transfer by trauma team. mother called for update from FL. limited info given per HIPPA guidelines.\n\nplan- wean o2 as tol. check ABG this am. transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2174-05-08 00:00:00.000", "description": "Report", "row_id": 1660855, "text": "npn\nneuro: pt aox3, some anxiety over possible bronch tomorrow\npain; c/o pain in back area toradol given prn as well as standing dose of ms contin with good effect\ncad hr sr 80-90's nbp 90/55 to 113/64 no issues\nresp: ls left side remains crackles with dim base, pt has intermittent coughing episodes but unable to produce sputum for cx, nrb off once oob to chair and has been on nc 4l all day with sats 99%. rr teens.\ngi: bs+ diet advanced to clears with npo p mn for ? bronch in am\ngu: voided on commode with 450cc out of clear yellow urine , cx and ua sent.\nid: emp 99 range, received toradol in am for pain and temp. unable to obtain sputum cx\nendo no ssi coverage needed.\nplan: ? bronch in am, medicate for pain prn, cont to monitor resp status and titrate o2 as needed. emotional support for anxiety\n\n" }, { "category": "Radiology", "chartdate": "2174-05-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1013984, "text": " 10:58 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval left pleural effusion\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with drainage of left pleural effusion - 1L removed\n REASON FOR THIS EXAMINATION:\n eval left pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Drainage of left pleural effusion.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n substantial decrease in the opacification in the left hemithorax following\n thoracentesis. Although the image is somewhat dark, no definite pneumothorax\n is appreciated. Extensive airspace consolidation is seen involving the lower\n half of the left hemithorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1013790, "text": " 6:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Post thoracentesis left\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with left effusion\n REASON FOR THIS EXAMINATION:\n Post thoracentesis left\n ______________________________________________________________________________\n WET READ: PXDb SAT 9:25 PM\n Left lung opacity, worst, may reflect rexpansion pulmonary edema post\n thoracentesis or atelectasis/pneumonia. The change in effusion is difficult to\n comment due to confluent left lung opacity, which spares a part of the left\n upper lobe\n\n \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:57 P.M., .\n\n HISTORY: Following left thoracentesis.\n\n IMPRESSION: AP chest compared to :\n\n Small left pleural effusion is appreciably smaller following left\n thoracentesis, and there is no pneumothorax, but there is an appreciable\n increase in consolidation in the left mid lung, which could be due to\n reexpansion edema or pulmonary hemorrhage if there was inadvertent lung\n trauma. Mild displacement of a relatively acute fracture of the left seventh\n rib laterally makes the fracture more readily visible than it was in\n retrospect on . Right lung clear. Heart size normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1013941, "text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with pna and pl eff.\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n As compared to the previous radiograph, there is no major change. The\n extensive left-sided parenchymal opacities have not increased. They still\n occupy two-thirds of the left hemithorax. The aspect of the right lung and\n the visible parts of the cardiac silhouette are also unchanged.\n\n\n" }, { "category": "ECG", "chartdate": "2174-05-07 00:00:00.000", "description": "Report", "row_id": 113737, "text": "Baseline artifact. Sinus tachycardia. Low QRS voltage in the limb leads.\nOtherwise, findings are within normal limits. Compared to the previous tracing\nof there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2174-05-07 00:00:00.000", "description": "Report", "row_id": 113738, "text": "Sinus rhythm. Findings are within normal limits. Compared to the previous\ntracing of there is no significant diagnostic abnormality.\n\n" } ]

[ { "category": "ECG", "chartdate": "2106-12-05 00:00:00.000", "description": "Report", "row_id": 191538, "text": "Baseline artifact\nProbable sinus rhythm with frequent atrial premature complexes and first degree\nA-V delay - possible multifocal atrial tachycardia\nModest nonspecific ST-T wave changes\nSince previous tracing of -06, atrial ectopy increased\n\n" }, { "category": "ECG", "chartdate": "2106-12-05 00:00:00.000", "description": "Report", "row_id": 191539, "text": "Sinus rhythm\nAtrial premature complexes\nFirst degree A-V delay\nLeft atrial abnormality\nModest nonspecific ST-T wave changes\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2106-12-04 00:00:00.000", "description": "Report", "row_id": 191540, "text": "Sinus rhythm. Prolonged P-R interval. No previous tracing available for\ncomparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2106-12-05 00:00:00.000", "description": "Report", "row_id": 1300868, "text": "NPN, 1900-0700\nneuro: AAO x 3; PERRLA, . No focal deficits. C-collar and log roll precautions maintained. Q2h neuro checcks. Pt has chronic back pain, exacerbated by supine position; good relief w/ fentanyl small doses, and frequent log roll, back rubs.-\n\nCV: 1st degree AVB, freq PAC's. Pulses palpable throughout. Serial EKG's show evolving AMI. Serial CPK's descending. No CP/SOB throughout shift. Low dose metoprolol for cardiac protection. Pboots.\nTransfused 1 unit PRBC for hct 28 r/t MI, age.\n\nPulm: BS CTAb. NP 2 4L-->> O2 sats >95%. CDB, IS q2-3 hrs.\n\nGI: abd scaphoid, soft. BS hypoactive. NPO execpt for sips w/ meds. No stool.\n\nGU: F/C urine clear yellow, 40-60cc/hr. Labs show unchanged CRF.\n\nMusculoskeletal: left lower arm in sugar splint w/ ventral support for fx digits. + hand/digit edema; ++ecchymosis.\n+ doppler signals of digits. Elevated well above heart. Minor abrasion left forehead.\n\nEndo: RISS, none required.\n\nID: Tmax 98po. Cefazolin gm 1 q 8hrs. MRSA swabs sent.\n\nP: serial EKG's q 6 x 2 (0600 & 12noon). 3rd serial CPK 0900. Clear TLS, c-spine ASAP. Careful assessment LUE for altered CSM; maintain elevation above heart. PRN fentanyl. Plan OR for open reduction, lac closure LUE on Monday.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-04 00:00:00.000", "description": "LUMBO-SACRAL SPINE (AP & LAT)", "row_id": 933494, "text": " 3:49 PM\n LUMBO-SACRAL SPINE (AP & LAT); T-SPINE Clip # \n Reason: fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p trauma\n REASON FOR THIS EXAMINATION:\n fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman, status post fall.\n\n LUMBAR SPINE, TWO VIEWS: The bones are diffusely osteopenic. There is\n exaggerated curvature of the lumbar spine. There are endplate degenerative\n changes in L1, L2, L4 and L5 causing mild loss of vertebral body height.\n\n THORACIC SPINE, TWO VIEWS: There are severe wedge compression fractures of T9\n and T12 of indeterminate age. There is anterior endplate loss of height of\n T10. There is exaggerated kyphosis of the thoracic spine. The bones are\n osteopenic. There is no alignment abnormality.\n\n IMPRESSION: Severe osteopenia. T9 and T12 severe wedge compression fractures\n of indeterminate age. Exaggerated kyphosis of the thoracic spine and lordosis\n of the lumbar spine.\n\n" }, { "category": "Radiology", "chartdate": "2106-12-04 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 933490, "text": " 3:11 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with fall and report of SAH\n REASON FOR THIS EXAMINATION:\n eval fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa SAT 3:57 PM\n Marked degeneration, no acute fracture or dislocation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with fall, report of subarachnoid hemorrhage.\n\n C-SPINE CT WITHOUT CONTRAST: There is no comparison. Note is made of marked\n degenerative changes with multiple levels and prominent lordosis, however,\n there is no prevertebral soft tissue swelling, and there is no evidence of\n acute fracture or dislocation. There is 1 cm low-density right thyroid\n nodule. The visualized portion of lung apices are unremarkable.\n\n IMPRESSION: Degenerative changes. Right thyroid nodule and calcified lymph\n node in the neck. No evidence of acute fracture or dislocation.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 933489, "text": " 3:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with fall and report of SAH\n REASON FOR THIS EXAMINATION:\n eval ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa SAT 3:48 PM\n High density along the sulci in the left frontal lobe, which can represent\n small SAH.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with fall, report of subarachnoid hemorrhage.\n\n HEAD CT WITHOUT CONTRAST: There is no comparison. Note is made of small\n amount of high density within the sulci of left frontal lobe, which may\n represent small amount of subarachnoid hemorrhage mentioned in the history. No\n other intracranial hemorrhage is noted. There is no shift of normally midline\n structures. Ventricles are not dilated. Differentiation of -white\n matters are within normal limit. The osseous and soft tissue structures are\n unremarkable.\n\n IMPRESSION: Small amount of high density along the sulci of the left frontal\n lobe, which can represent small amount of subarachnoid hemorrhage mentioned in\n the history. Clinical correlation and close followup is recommended.\n\n The wet read was flagged to ED dashboard.\n\n" }, { "category": "Radiology", "chartdate": "2106-12-04 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 933486, "text": " 3:05 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman status post trauma.\n\n AP SUPINE CHEST: The heart is normal in size. There is no pulmonary vascular\n congestion to suggest congestive heart failure. Lungs are clear. There is no\n pneumothorax or visualized fracture. There is probably a large hiatal hernia\n projecting posterior to the heart.\n\n AP PELVIS: There is no evidence of hip fracture or dislocation on this\n limited portable view. The pelvic ring appears intact.\n\n IMPRESSION: No evidence for hip or pelvic fracture or pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2106-12-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 933566, "text": " 8:30 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p fall\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: For followup evaluation of left subarachnoid hemorrhage.\n\n COMPARISON: at 15:41.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD WITHOUT IV CONTRAST: Again seen is a small amount of increased\n density within a sulcus of the left frontal lobe, as was seen previously. This\n appears similar in comparison to the prior exam. No new areas of intracranial\n hemorrhage are identified. The ventricles are symmetric, and there is no\n shift of normally midline structures. There are areas of low attenuation in\n the periventricular and subcortical white matter, consistent with chronic\n microvascular change. There is extensive calcification of the distal\n vertebral and cavernous and supraclinoid segments of the carotid arteries. The\n soft tissue and osseous structures are unchanged.\n\n IMPRESSION: Stable appearance of very small left subarachnoid hemorrhage. No\n new intracranial hemorrhage is identified.\n\n" }, { "category": "Radiology", "chartdate": "2106-12-04 00:00:00.000", "description": "L WRIST(3 + VIEWS) LEFT", "row_id": 933495, "text": " 3:50 PM\n WRIST(3 + VIEWS) LEFT Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p fall.\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman status post fall.\n\n LEFT WRIST, TWO VIEWS: Overlying cast material obscures bony detail.\n Fractures are seen through the distal radius and ulna with dorsal angulation\n of the distal fracture fragments. The appearance of this wrist is similar to\n the CT scan from 30 minutes ago and there is still significant misalignment.\n\n IMPRESSION: Continued malalignment of the distal radius and ulna fractures\n with dorsal angulation, not significantly changed from the CT scan 30 minutes\n earlier\n\n" }, { "category": "Radiology", "chartdate": "2106-12-04 00:00:00.000", "description": "LP HAND (AP, LAT & OBLIQUE) LEFT PORT", "row_id": 933541, "text": " 11:14 PM\n HAND (AP, LAT & OBLIQUE) LEFT PORT Clip # \n Reason: Assess fractures\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n F s/p fall with prox phalanx fractures\n\n REASON FOR THIS EXAMINATION:\n Assess fractures\n ______________________________________________________________________________\n FINAL REPORT\n LEFT HAND FOUR VIEWS\n\n Detail, particularly of the carpus, is obscured by an overlying plastic cast\n and positioning is suboptimal. There are oblique fractures of the bases of\n the third and fourth proximal phalanges. There is mild lateral angulation at\n the third proximal phalangeal fracture site as well as slight lateral\n displacement of the distal fracture fragment. The fractures of the distal\n ulna and radius were described on the patient's previous study. There are\n extensive osteoarthritic changes in the interphalangeal joints. The bones\n appear osteopenic.\n\n IMPRESSION: Limited study demonstrating fractures of the third and fourth\n proximal phalanges.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-04 00:00:00.000", "description": "CT UP EXT W/O C", "row_id": 933493, "text": " 3:30 PM\n CT UP EXT W/O C Clip # \n Reason: OPEN L WRIST FX\n ______________________________________________________________________________\n WET READ: MNIa SAT 4:15 PM\n DISTAL RADIAL AND ULNAR FRACTURE WITH DORSAL ANGULATION OF DISTAL FRACTURE\n FRAGMENTS.\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE LEFT WRIST WITHOUT CONTRAST.\n\n INDICATION: Open left wrist fracture.\n\n TECHNIQUE: CT scan of the left wrist was obtained without intravenous\n contrast. Images were acquired in the sagittal plane with the wrist overlying\n the patient's chest. Axial and coronal reformats were created and reviewed.\n No intravenous contrast was used. No comparisons.\n\n FINDINGS:\n\n OSSEOUS: There are a transversely oriented fractures of the distal radial\n metaphysis and distal ulnar metaphysis with dorsal angulation, dorsal\n displacement, and impaction. A separate small fracture is seen at the distal\n tip of the ulnar styloid. Alignment of the carpus with respect to the distal\n articular surface of the radius is maintained. Prominent degenerative changes\n of the carpus are also identified, including subchondral sclerosis of the STT\n joint, the first CMC joint, and the lunocapitate joint. Evaluation of the\n osseous structures for a small nondisplaced fracture is limited due to streak\n artifact from the patient's body. No definite additional fractures are seen.\n Degenerative changes of the CMC joints and the first MCP joint are also noted.\n\n Soft tissue swelling is noted diffusely about the wrist. There is also\n extensive vascular calcification.\n\n IMPRESSION:\n\n 1. Transversely oriented metaphyseal fractures of the distal radius and ulna\n with dorsal displacement, dorsal angulation, and impaction. No definite\n additional carpal fractures are identified, although evaluation is limited due\n to technique.\n\n 2. Degenerative changes of the wrist, most severe at the STT joint, first CMC\n joint, and first MCP joint.\n\n" }, { "category": "Radiology", "chartdate": "2106-12-04 00:00:00.000", "description": "L WRIST, AP & LAT VIEWS LEFT", "row_id": 933518, "text": " 6:15 PM\n WRIST, AP & LAT VIEWS LEFT Clip # \n Reason: post-reduction appearance\n ______________________________________________________________________________\n MEDICAL CONDITION:\n F s/p fall\n REASON FOR THIS EXAMINATION:\n post-reduction appearance\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old female status post fall with left wrist fracture.\n Please evaluate interval improvement in alignment.\n\n LEFT WRIST, THREE VIEWS: Detail is obscured by overlying cast material. Since\n the prior film from 2.5 hours earlier, there has been interval improvement in\n the degree of alignment of the distal radius and ulnar fractures. There is\n decreased dorsal angulation of the distal fracture fragments. The fingers\n are imaged on this view and there are mildly comminuted and angulated\n fractures of the proximal phalanges of the third and fourth digits.\n\n IMPRESSION: Interval improvement in angulation of the fracture fragments.\n Finger fractures as described above incompletely evaluated on these wrist\n views. Dedicated views of the left hand are recommended for better\n assessment.\n\n" } ]

[ { "category": "Echo", "chartdate": "2152-04-17 00:00:00.000", "description": "Report", "row_id": 79346, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Chest pain. Coronary artery disease. Mitral valve disease. Intra-op TEE for AVR and CABG\nHeight: (in) 66\nWeight (lb): 170\nBSA (m2): 1.87 m2\nBP (mm Hg): 125/63\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 16:29\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast in the body of the LA.\nNo spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Mildly\ndepressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter. Mildly dilated descending aorta. Simple atheroma in\ndescending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Moderate AS. Moderate to severe (3+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm.\n\nConclusions:\nPRE-BYPASS:\n1. No mass/thrombus is seen in the left atrium or left atrial appendage. No\natrial septal defect is seen by 2D or color Doppler.\n2. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is moderately dilated. Overall left ventricular systolic function is\n45%.\n3. Right ventricular chamber size and free wall motion are normal.\n3. The descending thoracic aorta is mildly dilated. There are complex (>4mm)\natheroma in the descending thoracic aorta.\n4. There are three aortic valve leaflets. The aortic valve leaflets are\nseverely thickened/deformed. There is moderate aortic valve stenosis. Moderate\nto severe (3+) aortic regurgitation is seen.\n5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n6. There is no pericardial effusion.\nPost- Bypass:\n\nNormal RV systolic function.\nA bioprosthetic valve is seen in the native aortic position, well seated and\nfunctioning well with residual peak andm mean 15/7.\nOverall LV EF is 45% on epinephrin 0.02mcg/kg/min\nAscending aorta is ilar to prebypass\n\n\n" }, { "category": "Echo", "chartdate": "2152-03-29 00:00:00.000", "description": "Report", "row_id": 79347, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis\nHeight: (in) 56\nWeight (lb): 170\nBSA (m2): 1.66 m2\nBP (mm Hg): 107/60\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 15:40\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Dilated LV cavity.\n\nAORTA: There are complex (>4mm) atheroma in the aortic arch. There are complex\n(>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. No masses or\nvegetations on aortic valve. Severe AS. Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Moderate mitral annular calcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. No abscess of tricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). Local anesthesia was provided by benzocaine topical spray. The\nposterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related\ncomplications.\n\nConclusions:\nThe left atrium is dilated. No spontaneous echo contrast or thrombus is seen\nin the body of the left atrium/left atrial appendage or the body of the right\natrium/right atrial appendage. No atrial septal defect is seen by 2D or color\nDoppler. The left ventricular cavity is mildly dilated. There is mild\nsymmetric left ventricular hypertrophy with normal systolic function\n(LVEF>55%). There are complex (>4mm) atheroma in the aortic arch and in the\ndescending thoracic aorta. The aortic valve leaflets are severely\nthickened/calcified, with at least moderate aortic stenosis (gradient not\nassessed in this study). No masses or vegetations are seen on the aortic\nvalve. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. No mass or vegetation is seen on the mitral valve. Mild\n(1+) mitral regurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence for endocarditis. Moderate aortic\nregurgitation with at least moderate aortic stenosis. Complex thoracic aortic\nplaque.\n\n\n" }, { "category": "Echo", "chartdate": "2152-03-28 00:00:00.000", "description": "Report", "row_id": 79348, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease.\nWeight (lb): 170\nBP (mm Hg): 105/38\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 11:46\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler. The IVC is normal in diameter with appropriate phasic respirator\nvariation.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Low normal LVEF. No resting LVOT gradient. No LV mass/thrombus. No\nVSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nMildly dilated ascending aorta. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Aortic valve\nvegetation/mass cannot be excluded. Severe AS. Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Cannot exclude\nmass or vegetation on mitral valve. Moderate mitral annular calcification.\nMild thickening of mitral valve chordae. Calcified tips of papillary muscles.\nNo MS. Trivial MR. [Due to acoustic shadowing, the severity of MR may be\nsignificantly UNDERestimated.] Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Normal tricuspid valve supporting structures.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews. The absence of a vegetation by 2D echocardiography does not exclude\nendocarditis if clinically suggested.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Overall left\nventricular systolic function is low normal (LVEF 50%). No masses or thrombi\nare seen in the left ventricle. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. The aortic valve leaflets are severely thickened/deformed.\nAn aortic valve vegetation/mass cannot be excluded. There is severe aortic\nvalve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. A mass or\nvegetation on the mitral valve cannot be excluded. Trivial mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion. The\nabsence of a vegetation by 2D echocardiography does not exclude endocarditis\nif clinically suggested.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-03-29 00:00:00.000", "description": "Report", "row_id": 1319861, "text": "add; abg 7.47 32 115 . vent change made, rate decreased to 10 from 14, next gas 7.43 39 94 127 . true hct 29.6. svr increased >700-800. ogt placement confirmed via xray ok to use. tylenol given and neutraphos also.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-29 00:00:00.000", "description": "Report", "row_id": 1319862, "text": "Respiratory Care\nRespiratory rate decreasted secondary to resp alkalosis.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-29 00:00:00.000", "description": "Report", "row_id": 1319863, "text": "Respiratory Care\nPt continues to be orally intubated/ventilated. BS: decreased bilaterally. Suctioned for thick tan secretions. Spiking temp-antibiotics. TEE negative. PSV trial failed due to Resp rate 5-6. Continues on Dopa at this time. Plan to continue with PSV trial/SBT in hope of extubation. Will continue to closely monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-30 00:00:00.000", "description": "Report", "row_id": 1319864, "text": "CCU NPN 1900-0700\nO: 75YO female with hx critical AS, DVT, ischemic cardiomyopathy transferred from OSH with decompensated heart failure req. intubation. fever to 103 on admit with no source to date. unable to wean dopa gtt. PA swan placed showing ? septic picture. r/o'd for MI. failed PS trial - contin. on AC. CT following for possible valve.\n\novernight:\nID: TM 100 coreblood temp. tylenol x1. BC pnd. urine no growth. vanco q24hr and aztreonam qq8hr sputum showing 3+ GPC pairs/clusters- possible PNA.\nCV: BP trending down to low 90's/ by 2300 with HR in 90's ST(from 70-80's earlier). discussed with team - dopa titrated up to 7mcq/k/min (from 6). 00- HR 120-130's ST with BP dropping to 70's/. 250cc bolus given. dopa . to 5mcq and then changed to levo gtt by 0015. levophed titrated up to .119mcq/k/min with good effect. HR coming down to 70-80 baseline and BP 110-120/40's. MAP 60's. no VEA.\n- no EKG changes.\nC.O. 8.2/4.2/449 on dopa gtt -> improved to 5.9/3.0/529 on levophed.\nPAP 36-50/19-25. CVP 7-10.\n\npt. denied CP/SOB/palps during episode.\n\nResp: remains on vent AC 500x10/.40/5peep. sats 98-100%. suctioned for small tan thick secretions. LS course bases.\nGU: foley 20-40cc/hr. neg. 150cc for and pos. 200 LOS.\nGI: no stool. pos. BS. TF started at 0100 promote with fiber at 10cc/hr. advanced to 20cc after 4hours. minimal residuals. aspirates are still guiac pos. but appear more bile color.\n\nheme: HCT 29.9\nNeuro: pt. more awake tonight, often coughing/frowing and appearing anxious/frustrated with events. writing \"when will this stop\". major complaint is ETT bothering her. versed gtt increased to 1mg/hr /fent remains at 25mcq/hr. also given prn boluses with good effect q2-4 hours. MAE. hands left unrestrained.\n\naccess: right rad. aline/right IJ swan\nskin: intact. no issues.\n\nA/P: titrate levo for desired effect. follow C.O./uo. BB on hold. follow HCT. advance TF to goal.\nGI aspirates showing improvement: contin. PPI. HCT stable.\nanxiety/discomfort- titrate sedation for comfort depending on plan for weaning.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-30 00:00:00.000", "description": "Report", "row_id": 1319865, "text": "Respiratory Care\nPt continues to be orally intubated/ventilated. Alert and oriented. BS: Coarse bilaterally-suctioned for moderate amounts of thick tan secretions. Pt changed from A/C ventilation to PSV this am. Currently on /.40 with tidal volumes ranging from 350-450cc's and respiratory rate in the mid-20's. Hope to wean towards extubation in the AM. Will continue to closely monitor at this time.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-30 00:00:00.000", "description": "Report", "row_id": 1319866, "text": "NPN 7 AM-7PM\nS: \" am I getting enough oxygen?\"\no: please see careview for vitals and other objective data.\npt here with fever, chf, AS, PNA, on ventilator with PA line for fluid management and hemodynamics. Being weaned today and off drips as of 4 pm. appears to be spiking fever again at 5:30 pm.\nNeuro: pt alert all day, somewhat anxious at times writting notes, \" I have to go the bathroom again\" and \" how is my oxygen?\" On versed 0.25 mg per hour and fentanyl 25 MCG per hour. naps when not disturbed. PERL, moves all extremities, hand grasps, follows commands, OX3.\nRESPIRATORY: pt was on AC this AM, RSBI high, However at 0930 we were able to wean her to 12PS and 5 peep, then later 12 noon 10PS and 5peep.\npt tol well, RR 19 -22, o2 sat 98-100%, ABG checked and reviewed with resident MD. ABG at 430pm 7.37 40 141 99 %\npt has thick tan secreations, suctioned Q2-3 hours. good cough when turned and suctioned.\nCardiac: HR 70-80 most of day SR with occasional PVC, k 3.9 Dr aware, Able to wean off Levophed over course of day, MAP low when pt sleeping (56) then up to 60's most of day. CO/CI Q 6 hours MD\nstable today- CVP-7 CO 5.7 CI 2.92 svr- 940 PAWP 17. + pulses. waves all WNL please see progress notes for wedge and pa tracings. HG dropped to 8.9 will resend H and H per dr. ().\n pt with sparse gram neg rods on sputum, culture and sensitivity to follow, Pt spiked again today 101.0 core at 1730. Md updated ordered BC x 2, UA. continues on antibiotics.\nskin: mM intact, skin intact, slight pink spot on buttocks aloe vesta applied.\nGI: pt was tolerating tube feeding at 20 cc per hour, residuals were 5 cc and 20 cc, I increased the feeding to 30 cc and at 1600 residual was 50cc. will turn off tube feeding x 2 hours and recheck residual at 1830. Pt has soft semi formed stool, yellow brown, guiac negative. also ngt aspirate also negative and ph .\nendocrine FS q ac and hs, 140, 132, 102.\nSocial: Family here to see pt, husband, updated on plan of care, husband spoke to as well. appears to understand the situation.\nA: pt with AS, PNA, intubated, neg endocarditis by TEE, cultures pending, now spiked a temp again. beig weaned off ventilator on PS 10\npeep 5\nP: reculture pt, tylenol for fever, monitor respiratory status and Q 6 hour hemodynamics. follow Blood glucose, H and H, support pt and family and keep them updated on POC as discussed in multidiciplanary\nrounds.\n RN\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-03-31 00:00:00.000", "description": "Report", "row_id": 1319867, "text": "Resp CAre\npt remains on vent. Intubated with 7.0ett @ 20. Patent and secure. suctioned mod amt of thick yellow secretions. Placed on Ac overnight due to poor abgs and wob when on PS. Increased fio2 based abgs. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-31 00:00:00.000", "description": "Report", "row_id": 1319868, "text": "CCU NPN 1900-0700\nS: Pt remains orally intubated and mechanically ventilated.\n\nO: Please see careview for VS and additional data.\n\nCV: HR 68-90 NSR, ABP 86-117/35-44, MAPs 51 (levo started) to 77, PADs 15-28, PCWP 21 (correlated with PAD 22), CVP 5-14. At approx 0340 pt MAPs decreased to 51-55, CVP 12-Dr. notified and levophed gtt restarted at 0.05 mcg/kg/min for goal MAPs >60, levophed gtt presently 0.06 mcg/kg/min. Most recent cardiac numbers CO 6.9/CI 3.54/SVR 533-Dr. notified, please see careview for additional cardiac numbers. Bilateral pedal and radial pulses palp. Am HCT 27.1, K 4.9, Mg 1.9. Ca 7.9.\n\nResp: Received pt on CPAP+PS-at approx 2300 pt noted with increased WOB, coughing-pt switched to AC, please see careview for all vent settings and ABGs, pt presently on AC 50% 500 x 10 5 peep. Pt sxn'd for sm to mod amts thick yellow-tan sputum. Strong cough/gag noted with suctioning, oral care. LS clear to diminished/coarse throughout.\n\nNeuro: Pt sedated on fentanyl 50 mcg/hr and versed 1 mg/hr, pt easily , , assists with turning. Bilateral grasp appears equal. Pupils equal, brisk reactive to light. At start of shift pt nodding head yes to anxiety/frustration, (sedation increased at 1900), pt also given prn boluses with turning, sxn'ing, etc with good effect. Pt nods head no to all pain. SWR on for pt safety as pt hands noted on tube.\n\nID: Pt T max 101.5 blood, HO aware-bld cx's pending. Am WBC 3.9, pt cont on aztreonam.\n\nGI/GU/ENDO: Pt abd soft, + BS x 4, no stool this shift, TF held briefly d/t increased residuals-HO aware, TF resumed this am. Pt with foley cath drianing clr yellow u/o 20-30 cc/hr-Dr. notified, no intervention at this time. FS 107 and 125-no ss insulin coverage indicated.\n\nSocial: No calls or visitors .\n\nA/P: 75 y/o female with severe AS, 1+ MR and 1+ TR, restarted on levo gtt for goal MAPs >60, cardiac numbers ?septic picture. Continue to monitor pt hemodynamics, cardiac numbers. Continue to monitor resp status, u/o, cx's, temps. Continue to provide emotional support to pt-wean sedation as tol/pt comfort, advance TF as tol. Awaiting further POC per CCU Team.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-31 00:00:00.000", "description": "Report", "row_id": 1319869, "text": "NPN 7AM - & PM\nS: intubated and sedated\nO: please see careview for vitals and other objective data.\nPt with AS, LLL PNA, and CHF, ? of GI bleed now. After a good day yesterday,weaning off the ventilator and doing fairly well, pt had in the evening spiked a temp, and was placed back on ventilator on assist control, and sedated. We cultured urine and blood at that time.\nLater, she was placed back on levophed drip for hypotension.\nthis AM her temp was 100.4, down to 98.9, remains on the ventilator AC mode, BP maintained on levophed drip, antibiotics for PNA.\nNeuro: pt is sedated but does arouse, writting notes, asking questions\nabout her illness,perl, strong hand grasps, follows commands.\nCV: pt remains in SR with occasional PVCs, HR 60-70's, positive pulses, wedge 17, cvp 10. PA 35/18 . bp was lowish this am 100/39\nbut now up to 120's systolic, map 60-70.\nRespiratory: no weaning today, pt remains on AC rate of ten, 50 FIO2,\nsuctioning Q2 hours and with position changes, more productive of sputum, thin tan secreations to thick brownish/tan with small plugs.\n02 sats 96-98%,, lungs are coarse to rhonchi anterior with rales\nbases. pt coughs and gags on tube turns ruddy red, but improves with\nsuctioning. please suction oral larangeal( above cuff) also, producing copius amounts oral secreations. Antibiotics have been adjusted, vanco increased secondary to lowish trough, and levofloxacin was added.\nGi: pt has been off of tube feeding most of the day, high residuals this AM, 45 cc, later 35 cc. spoke with md, ngt aspirate dark brown,\nbile, no coffee grounds, guiac positive. Md updated, Dr. \nordered hold tube feedings for now. following HCT for ? GI bleeding.\nno stool since yesterday.\nGU: urine output 25-30 cc hour, MD aware. Repeat urine culture sent, at request of Lab.\nA: pt with LLL PNA, on ventilator, on levophed drip for hypotension,\npa catheter for hemodynamics and on antibiotice. gram neg on sputum C and S pending.\nP: continue monitor resp status, and no plan to wean today. may attemp weaning again tomorrw if pt remains afebrile. Monitor rhythm, Hemodynamics, follow HCT and k, glucose and ABG's. Sedate pt, and suction frequently.\n RN\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-03-31 00:00:00.000", "description": "Report", "row_id": 1319870, "text": "BS coarse crackles. Sx'd for mod amt thick yellow secretions. Low grade temp likely PNA. Will continue to attempt on PSV tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-31 00:00:00.000", "description": "Report", "row_id": 1319871, "text": "NPN 3 pm - 7 pm\naddendum: pt mostly stable this afternoon, weaning down Levophed, almost off. pt anxious at times, vewrsed bolus 1 mg ivp with good effect. Updated DR. regarding wedge(21) and hemodynamics, ekg, ABG, md ordered decrease vent to 40 percent, Fio2, resp aware.\nat 1845 pt temp noted to be 102.0 core, md paged. tylenol 650 ngt.\n RN\n" }, { "category": "Nursing/other", "chartdate": "2152-04-01 00:00:00.000", "description": "Report", "row_id": 1319872, "text": "Resp Care\nPt remains on vent. No changes made. suctioned mod amt of thick yellow secretions. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-04 00:00:00.000", "description": "Report", "row_id": 1319889, "text": "CCU Nursing Note\nS-\"It feels good to have the breathing tube out.\"\nO-see flowsheet and admission note for additional details/assessment data.\n\n75y.o female admitted c CHF exacerbation c/b pna and sepsis. Now recovering and awaiting AV Repair.\n\nEvents: Off Levophed since 0730. Dosed 40mg Lasix c good response then Extubated @ 1000 p difficulty. O2 weaned as low as 3L NC. @ 1600 complaints of SOB although sats >97%. Dosed Atrovent neb. BP increased started on 12.5 PO Lopressor. RR/SBP continued to increase- @ 1630 pt became tachycardic to 110, SBP up to 170s, RR 33, and diaphortic. ABG 7.36/52/112. Denied CP and EKG unremarkable. Recieved IV Lopressor 5mg x3, 40mg Lasix, and 2mg morphine x2. Transferred from non-rebreather to BIPAP c 10PS, 6peep, 50%O2, TV 400. SBP down to 130s, sat 100%-although RR continues in high 20s. S/P BIPAP ABG 7.35/49/108.\n\nCV-Off pressor. Lopressor started-now switched to IV. SBP 120s-150s aside from Resp distress incident. RIJ TLC WNL. R-radial a-line sharp. All pulses palpable.\n\nR-Extubated 1000 c/b resp distress 1600 see above. LS coarse c crackles throughout shift. Minimal secreations when on vent as well as s/p extubation. C&DB encouraged practiced IS. Right middle lobe pna c GPC. Chest x-ray s/ showed slightly worsening fluid accumulation. Tolerating Bipap-Now denies SOB c RR 25-30. Continue to monitor closely.Denies pain/anxiety.\n\nN-a/ox3, MAE, PERRL, following commands consistently.\n\nID-Off percautions. MSSA in Sputum. Tmax 99.8. Remains on triple abxs.\n\nGI/GU-+BS, -BM. Speech and swallow consult pending. Tolerated sips/chips earlier in shift.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-04 00:00:00.000", "description": "Report", "row_id": 1319890, "text": " NPN, event note:\npt co bipap mask too tight, unable to breathe right, anxious. gave mso2 2 mg, ativan 0.5 mg with fair effect. Respiratory came by and pt placed on 60 aerasol shovel mask. lungs clear a and p.\npt expressed relief, \"I can breathe better this way\", will follow closely.\no2 sats 97-98 percent. RR 23-26.\n \n" }, { "category": "Nursing/other", "chartdate": "2152-04-04 00:00:00.000", "description": "Report", "row_id": 1319891, "text": "NPN 2200\npt off BiPAP x 1.5 hours, abg drawn, reviewed results with rounding resident.MD updated, pt feels she is breathing easier on face mask, however lungs with more crackes post Bipap. RR down to 24-26 and o2 sat stable.\nMD , ordered keep pt on shovel mask, follow closely.\n RN\n" }, { "category": "Nursing/other", "chartdate": "2152-04-05 00:00:00.000", "description": "Report", "row_id": 1319892, "text": "NPN event note 0045\npt became actely SOB at 1130 pm. she had been off bipap for 3 hours,\nlung sounds rales and exp wheezes. MD came by, lasix 60 mg IVP and lopressor 5 mg IVP. pt placed back on Bipap by respiratory.\npt improved on Bipap, lungs sound clear anteriorly, rr down from 28=30 24-25 bpm. ABG sent and reviewed with dr , repeat abg sent at 1245 am, results pending. Pt is improved, will monitor.\n RN\n" }, { "category": "Nursing/other", "chartdate": "2152-04-05 00:00:00.000", "description": "Report", "row_id": 1319893, "text": "NPN 7 PM-7AM\ns: \" what if I stop breathing, then what?\"\nO: please see careview for vitals and other objective data.\npt with aortic valve stenosis, CHF and PNA, extubated Tuesday\n at ten am. pt has not been tolerating extubation well.\ntuesday she decompensated 6 hours post extubation with increased rales, tachycardia and increased BP, she was tx with lasix, lopressor and placed on BIpap. tueday evening pt struggled with Bipap mask and we had her off pap for three hours, however, she again decompensated, had flash pul edema? was tx'ed with IV lasix, metropolol,MSO4,albuterol and then placed back on Bipap at 1130 pm.\ncurrently pt tol Bipap but is anxious, ativan and mso4 given with good effect, currently resting comfortably.\ncardiac: pt with chf, pna aortic stenosis, remains in SR 70-80's with rest up to 90's when anxious. on lopressor 5 mg IV Q 4 hours,\nBP 120-130 systolic, up to 150's during episode of pulmonary edema.\ndiuresed 600 cc urine post lasix.\nRespiratory: pt on BiPAP/CPAP via face mask, 40 fio2, 5 peep, 10 PS,\nLungs still with rales ant and post, faint exp wheeze at times, complains about face mask and anxious that she will be re intubated.\nwe are following ABG's , all results with MD, O2 sats remain 96-98 percent. RR 22-24.\nNeuro: pt is oriented, moves all extrem, writes notes.\nGI- soft abd, yellowish bruise still present since last week, positive bowel sounds, soft abd, NPO for now.\nGU- responding to lasix, clear yellow urine from foley.\nskin- remains intact.\nID- remains on triple antibiotics, vanco trough to be drawn at 0600 am.currently afebrile 97.2 ax.\nA: pt with chf/ flash pulmonary edema, unable to breathe on her own with out assistance, may need to be reintubated, Dr. aware\nand has been by to check on pt several times.\np: monitor resp status, follow ABG's, O2 sat RR and lung sounds, follow cardiac status, give lopressor Q 4 hours and pt may need additional lasix. Give Mso4 2 mg prn , and or ativan for anxiety.\nReassure pt. keep pt NPO, pt and family updated on POC as discussed in multidiciplanary rounds.\n RN\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-03-29 00:00:00.000", "description": "Report", "row_id": 1319859, "text": "CCU NPN 1900-0700\nS/O:\n\nID: TM 99 core. contin. ceftriax IV . BC/urine cultures pnd from . sputum GPC- pnd.\n\nCV: HR 69-80SR. occas. PVC. BP 99/39-130/46. MAP 55-70. dopa weaned from 8.5mcq to 6.0mcq/k/min.\nheparin gtt restarted at 2100 at 950u/hr(no bolus). PTT pnd.\nPAP 32/17-41/24. CVP 9-14.\nMVO2 69-70. C.O. 5-5.7/2-2.9/1100->744. HO aware.\ninitially unable to wedge PA catheter. resident advanced catheter to 49cm (had apparently floated out). has remained at 49cm throughout night and able to wedge.\n\nAM K+ 3.9/Mg 2.4.\n\nHeme: AM HCT 31.7 (36.9). GI aspirates brown/guiac positive. no stool. heparin gtt d/c'd at 0545. repeat HCT pnd at 0600. protonix increased to .\n\nResp: AC 500x14/5peep. FIO2 decreased to .40 at 0530. sats 99%. ABG (on .50) 7.47/38/152. suctioned for thick tan secretions. LS course.\n\nGU: foley 40-60cc/hr. yellow\nGI: no stool. remains NPO for possible TTE.\nendo: FS 160- SSRI. no hx of DM\nneuro: pt. wakes easily to name or stimulation. alert, looks around room and tracks. MAE and follows commands approp. denies pain other than ETT. periods of increase restlessness/agitation req. versed bolus 1-2mg with good effect. versed gtt increased to 2mg/hr...fent remains at 50mcq/hr. bilat. wrists restraints for safety. allowed to scratch face with close supervision.\n\nright fem. site C/I.(old TLC). right IJ PA line. right rad. aline. OGT/ETT.\n\nA/P: follow HCT. hep. d/c'd. follow GI aspirates. check ABG's/C.O. contin. to wean dopa as tol.\n- fent/versed for comfort. NPO. ? TTE today.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-03 00:00:00.000", "description": "Report", "row_id": 1319883, "text": "NPN CCU 0700-1900\n\n75 y/o female w severe AS, Pnx, intubated .\n\nS/O: PT ABLE TO COMMUNICATE BY WRITING. ABLE TO MAKE NEEDS KNOWN.\nSEE CARVUE FOR COMPLETE OBJ DATA.\n\nMS: MAE, WRITING OUT STATEMENTS, ORIENTED TO PERSON & PLACE, REORIENTED TO TIME EASILY. ON .5MG VERSED, 25MCQS OF FENTANYL PER HR.\nDENIES PAIN. SWR OFF ALL DAY, NO ATTEMPT TO ETT.\n\nCV: HR 60'S. LEVOPHED AT .03MCQS/KG/MIN TURNED OFF ON ROUNDS THIS AM. MAPS IN THE 50'S , OK PER TEAM, GOAL SBP>90. SBP REMAINS > 90 OFF OF LEVOPHED, U/O DROPPED OFF < THAN 15CC/HR. TEAM AWARE, LEVOPHED RESUMED WITH ^ 30CC/HR DARK CONCENRATED URINE.\n\nRESP: ON CPAP THIS AM , DECREASED BS, NO RALES/RHONCHI, DECREASED SECRETIONS, TV 300-350, RR 28. AM RISBI 133, FAILED BREATHING TRIAL. ABG DRAWN ON CPAP X'S 2, ACCEPTABLE AND UNCHANGED. PT APPEARS TIRED/LABORED W/ WORK OF BREATHING. AC .40/500X10 5 RESUMED.\n\nGI: TF'S RESUMED AT 1130AM AT 50CC/HR. RESIDUALS, 40 CC. +BS, NO STOOL, ABD SOFT.\nGU: BUN CREAT WNL, DECREASED U/O OFF OF LEVOPHED.\nID: AFEBRILE TEMP MAX 100.3 RECTALLY, ON TRIPLE ABX. SPUTUM + FOR STAPH AUREAS GRAM + COCCI. PLACED ON CONTACT PRECAUTIONS.\nSKIN: WNL\n\nA/P: NOT TOLERATING VENT WEAN TODAY, DROP IN U/O WHEN LEVOPHED STOPPED ALTHOUGH SBP ACCEPTABLE >90. TF'S AT 50CC/HR\nLIGHT SEDATION TOLERATED WHILE WELL ON VENT.\nHOLD TF'S AT 4AM FOR BREATHING TRIAL. FOLLOW U/O, ? GIVE LASIX PRIOR TO SBT ?, CONT ABX, FOLLOW TEMP, FOLLOW TF RESIDUALS UNTIL D/C.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-03 00:00:00.000", "description": "Report", "row_id": 1319884, "text": "BS occ rhonchi; no MDI's given. CPAP on PSV 10 x 8 hr. Rate generally less than 30 but appeared to be laboring more than yesterday. Will try CPAP with PSV wean to 5 tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-04 00:00:00.000", "description": "Report", "row_id": 1319885, "text": "Resp Care,\nPt. remains intubated on A/C . RSBI 71 this am. Changed to IPS . VT 300's, RR 20's. ABG acceptable. Possible extubation today.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-29 00:00:00.000", "description": "Report", "row_id": 1319860, "text": "CCU NPN 0700-1900\n\nS/O: PT ABLE TO ASK QUESTION BY WRITING THEM OUT. ASKING, \"WHEN DID I GET HERE\" \"WHAT DAY IS IT\"\nSEE CAREVUE FOR COMPLETE OBJ DATA\n\nMS:AS ABOVE, WRITING OUT QUESTIONS, PT SEEMS TO BE FORGETFUL. LIGHTLY SEDATED ON .5MG/HR VERSED GTT AND 25 MCQ/HR FENTANYL GTT. BOLUSED W/ 2.5MG VERSED, 150MCQ FENT FOR TEE. NO ATTEMPTS TO REACH FOR ETT, SWR OFF ALL DAY.\n\nCV : DOPAMINE REMAINS ON 6MCQ/KG/MIN, BP 102/38 MAP 59-60. BP DROPS WHEN SLEEPING, INCREASES WHILE AWAKE. HR 68-80. +CAP REFILL, EXTREMITIES WARM TO TOUCH, PALPABLE PEDAL PULSES.\n12N MVO2 DECREASED 68 TO 64, 12N SVR 688(MAP WAS 60) FROM 966. 12N ^CO/CI 5.7/2.92.\nNEXT HD NUMBERS PENDING 4PM DRAW.\nTEE, NEG FOR VEGITATION/CLOT. HCT 29-32, HGB 10.8-9.7. +BLEEDING FROM BACK OF THROAT POST TEE, SXN'D CLEAN. INR 1.4, HCT HCT DRAW AT 1800, IRON STUDIES ADDED ON TO LABS. SQ HEP STARTED.\n\n\nRESP: AC .40 500 14 5, ABG'S 7.45, 34 98 0 24. PRESSURE SUPPORT TRIAL ATTEMPTED, RR DROPPED TO 5.6. RETURNED TO AC.\nSXN'D Q 3 FOR THICK TAN SECRETIONS.\n\nID: SPUTUM CX + FOR 3+GRAM POS COCCI,ONLY CX GROWTH TO DATE, REMAINS ON IV ABX. VANCO LEVEL THIS AM 5.7, DOSE GIVEN. AFEBRILE, T MAX CORE 100.3 TYLENOL GIVEN THIS AM VIA OGT.\n\nGI: SCANT AMOUNTS OF OLD COFFEE GROUNDS NOTED IN OGT, UNABLE TO ASP ANY SIG RESIDUALS. REMAINS NPO. PROTONIX IV. +BS, NO STOOL.\n\nGU: CLEAR YELLOW URINE VIA FOLEY, 20MG IV LASIX GIVEN TODAY CREAT 0.8.\nSEE CAREVUE I&O.\n\nSOCIAL: HUSBAND AND DTR IN TO VISIT THIS AFTERNOON, WILL RETURN .\n\nA: TMAX 100.3 ON IV ABX, LOW SVR, CO/CI INCREASED, WBC 7.1. BP REQUIRING IV DOPAMINE FOR MAPS >60. ABG STABLE ON CURRENT VENT SETTINGS. TEE NEGATIVE.\nP: LIGHTEN SEDATION AS TOLERATED, RISBI/PS TRIAL AS TOLERATED. FOLLOW CO/CI/SVR.\nWEAN DOPMAINE AS TOLERATED. FOLLOW HCT. IV ABX, TEMP CURVE. ? IF WILL BE ABLE TO EXTUBATE IN AM.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-04 00:00:00.000", "description": "Report", "row_id": 1319886, "text": "CCU NPN 1900-0700\nO:\nTM 99po. contin. IVAB for GPC in sputum.\nRESP: on AC ventilation until 0400: RISBI 72- placed on PSV 5/5/.40 tolerated very well. RR 23-28. Tv 350-420.\nABG 7.37/45/172. suctioned for scant thick tan secretions. LS diminished.\nunclear fluid status picture. given 500cc fluid bolus initially with poor/no u/o responce. then gave lasix 40mg IV at 0100 with good responce - 600cc over 3hours. u/o contin. 60cc/hr. remains >3L pos. LOS.\n\nhopeful for extubation today.\n\nGI: TF on at 50cc/hr. high residuals in eve- stopped. restarted at lower rate and now off for possible extubation. no stool.\n\nneuro: pt. on versed .5mg/hr and fent 25mcq/hr. denies pain/. occass. noted for increase anxiety with suctioning/turning. given prn boluses 1mg versed x2 and 25mcq fent. x2 with good effect.\nmoving all extremeties. helpful with turns. able to communiate effectively with gestures, mouthing.\n\nA/P: tolerating PSV 5/5 this morning. TF off. ? plan for extubation. increase PS if pt. tiring.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-04 00:00:00.000", "description": "Report", "row_id": 1319887, "text": "Pt extubated this AM without incident. As day wore on she exhibited increased WOB and diaphoresis. Placed on NIV with ABG and CXR pending. Possible element of CHF. BS coarse crackles.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-04 00:00:00.000", "description": "Report", "row_id": 1319888, "text": "CCU Nursing Note\nNegative >than 2L for shift. Foley c CYU. Recieved Lasix 40mgx2. BUN/crt WNL.\n\nPlan-continue to monitor pulm status closely. RR remains high.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-28 00:00:00.000", "description": "Report", "row_id": 1319856, "text": "CCU Nursing Progress Note 1900-0700\nPt admitted to OSH after recent hospitalization and discharge. CHF exacerbation requiring intubation after continued decompensation. Cardiogenic shock secondary to preexisting AS requiring pressor support. Transferred to for further mgmt. Pt was scheduled for valvuloplasty in .\n\nCV/MS: Pt arrived VSS on Dopamine at 2 mcg/kg/min. Titrated gtt to 3.3 mcg/kg/min (10cc) to maintain MAP>60. Pt denies any pain. Arrived unsedated. AAOx3. Pleasant and cooperative. Pt MAE. PEARL. Soft wrist restraints applied to maintain integrity of invasive lines/ ETT.\nInitial assessment found pt to be febrile. 103. PR. HO aware. Per report from OSH pt was afebrile tmax 98.0. Pt was pan cultured and administered liquid Tylenol 650 mg x2. Repeat temp 102.1 po. Cont to follow. WBC still pendin.\nF/C to gravity. Draining sm amts of cyu. Abd obese,. +BS. Stool smear w/ PR temp. Guiac negative. BUN/Cr 27/1.0.\n\nResp: Received pt mechanically ventilated on AC vt 500*14/ 5 peep. Awaiting Arterial line placement to acertain ABG. Suctioned for scant bld tinged secretions. LS cta in apexes. Bibasilar rales. Pt denies SOB/ difficulty breathing. CXR revealed bilateral opacities indicating CHF. ? L pna. Awaiting sputum culture results.\n\nSkin: Intact. No breakdown. Areas of ecchymosis secondary to at home Lovenox for DVT prevention.\n\nEndo: BS wnl.\n\nSocial: Pt lives with husband and dtr. unable to travel w/ pt from OSH d/t inability to drive at noc. Plan on visiting sometime this am. No calls this am.\n\nA/P: CHF exacerbation/ Cardiogenic shock secondary to critical AS. ? Valvuloplasty. Cont pressor wean as tolerated. Cont gentle diuresis as indicated. Broad abx coverage for fevers of unknown etiology. Awaiting aline placement. Fentanyl/Versed for comfort. Cont supportive care. Keep pt and family updated in POC.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-03-28 00:00:00.000", "description": "Report", "row_id": 1319857, "text": "Respiratory Care\nPt continues to be orally intubated/ventilated at this time. BS: generally clear bilaterally. Pt spiking temps this am. Swan line placed. Fio2 successfully weaned t/o the day. Plan to maintain current support at this time. Will continue to closely monitor.\n" }, { "category": "Nursing/other", "chartdate": "2152-03-28 00:00:00.000", "description": "Report", "row_id": 1319858, "text": "NPN &am-7pm\nS: orally intubated\no: please see careview for vitals and objective data.\npt transferred from hospital this morning with Dx CHF,\nAS, ? cardiogenic shock and fever. Intubated enroute\ndue to resp distress. Currently intubated and mechanically vented, on antibiotics.\nNeuro: pt arousable, awakens to voice, MAE X 4, PERL\nobeys commands, writes notes. now sedated but arousable on\n50 UG/min fentanyl and 1mg/HR of versed.\nrespiratory: pt has been weaned off high O2, went from 80% this am to 50% Fio2 by 1 pm, tol well. remains intubated on AC rate 14, O2 sats 96-98 %. Clear anteriorly and rales at bases, no further lasix today UO avg 50 cc per hour. suctioned , small amount white secreations.\nCardiac: was hypotensive this AM, Dopamine was titrated up to 8.5 UG/KG/MIN to keep MAP around 65. BP was 89-98 this am but increased as sedation wore off and dopa was increased, by afternoon bp 120 systolic. pt had a PA line placed at 1500, reviewed Hemodynamics with\nIntern. CI 2.47, Pa wedge 20, cvp 10. Troponin pending, CPK was flat.\nHeparin, for ACS, was started at 0900, 4000 unit bolus and 950 units per hour, however MD dc'd drip at 10 am for insertion of pa line. Intern updated , ? of restarting heparin, they are consulting with team. Pt had echo today, results pending. remains in SR, hr 70-80 mostly. had SR with pac this AM and runs of Vtach during swan insertion ( MD aware), kcl and MG was repleated. now ocasional PVC's.\n pt NPO except meds, ngt in place, PH was 4 and no bleeding per gastrocult. ngt output, 100 cc bile. soft abd, + BS also pt has hernia\nwhich is evident when she coughs.\nID: pt with FUO, temp 103 this am, today temp 97.4 after antibiotics, cultures done pre antibiotics- results pending. Right fem line from was by MD at 1800. ? no source yet of fever.\nendo FS q ac and hs, pt is not diabetic, 151, 142, 173. no coverage.\nSkin- intact, mouthcare - tissue wnl.\nSocial, Husband and dtr called and visited, family updated on POC.\nA: pt with AS, waiting for valve surgery, here with repiratory failure, chf, fever, on antibiotics and now with PA line.\np: continue to trend troponin and CK, pt to have TEE tomorrow,\nfollow PA values and CI/CO, titrate dopamine to keep MAP 65,\nfollow resp status, ABG, neuro assessment. Keep family updated on plan of care as discussed in multidciplanary rounds.\n RN\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-03-28 00:00:00.000", "description": "Report", "row_id": 1319855, "text": "Respiratory Care\nPt. admitted to CCU from OSH. Intubated on ventilatory support. Size 7 ETT, 21 cm @lip. Appears awake and alert, cooperative. BS appear clear, but able to sx Pt. for thick blood tinged secretions. Sample obtained for culture.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-02 00:00:00.000", "description": "Report", "row_id": 1319877, "text": "CCU NPN: 1900-0700\n\nS: \"When is this going to stop?\" (written)\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 60s-70s, SR, occ. PVCs despite K+ 4.0, 4.2. Levophed titrated for MAP > 60. Transfused 1U PRBCs (after CVL retracted per CXR by CCU team) w/ post-transfusion Hct: 27.8.\n\nRESP: Remains intubated on AC/0.40/500/10/5 w/ latest ABG: 7.37/41/129/25/98%. Lung fields w/ scattered rhonchi - initiated Albuterol MDIs w/ mild improvement. Suctioned frequently for small-moderate amounts of yellow, thick sputum (ETT and oral secretions). PM CXR w/ persistent RUL PNA and improved CHF.\n\nGI/GU/ENDO: Abd. soft, non-tender, slight distention. BS hypoactive. Remains NPO d/t poss. GIB -> dark brown aspirates per OGT, OB+. No BM despite bowel regimen. Diuresed w/ 40mg Lasix during transfusion PRBCs w/ hourly UOP 32-330cc, -587cc for thus far. Stable renal fuction per AM labs. FS required no sliding scale coverage.\nID: Tmax 100.6 PO - remains on triple antibiotic coverage. WBC 6.3 this AM (5.5 ).\n\nNEURO: Dozing intermittently throughout night - anxious at times and frustrated w/ coughing. Reported feeling restless in evening and sedation increased slightly for sleep. Easily on Fentanyl and Versed infusions. Follows commands consistently. Husband updated via phone.\n\nA/P: Recent admissions for CHF exacerbation - known critical AS and was to tentatively have AVR at . Admitted from OSH for CHF exacerbation vs. Sepsis/PNA. New RUL PNA - triple antibiotic coverage, cultures pending. Random Vanco to be drawn at 0730 (pre-AM dose). Stable Hct w/ PRBC transfusion -> awaiting input from GI re: poss. UGIB -> NPO until further notice. Poss. AVR in future if ID issues resolve. Emotional support and comfort to pt. and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-02 00:00:00.000", "description": "Report", "row_id": 1319878, "text": "FOCUS; NURSING PROGRESS NOTE\n75 YEAR OLD FEMALE WITH PMH SIGNIFICANT FOR CRITICAL AS,DVT,ISCHEMIC CARDIOMYOPATHY, HYPERLIPIDEMIA, AND HTN. SHE PRESENTED TO THE HOSPITAL ON WITH SOB. WAS TRANSFERRED TO ON FOR DECOMP CHF AND LL PNA. SHE WAS SWANED WITH SEPTIC APPEARING NUMBERS.\nREVEIW OF SYTEMS-\nNEURO- SHE IS ON 25MCGS/HR OF FENTANYL AND .5MG/HR OF VERSED. ON THIS SHE IS . ABLE TO WRITE. FOLLOWS COMMANDS CONSISTENTLY. SHE MOVES ALL EXTREMITIES. PEARL.\nRESP- SHE IS INTUBATED AND VENTED. WAS ON A/C MODE OF VENT THIS AM. SWITCHED TO PS OF 10 PEEP OF 5 AND 50% FIO2. ON THIS SHE BREATHS IN THE MID 20'S WITH TV OF AROUND 350-380 CC. ON THIS SETTING HER ABG WAS 7.37/45/131/27. SHE HAS BEEN SUCTIONED FOR THICK YELLOW SPUTUM IN SMALL TO MODERATE AMOUNTS Q 2-4 HOURS. HER BS ARE RHONCHOROUS ON THE RIGHT DIMINISHED ON RLL AND COARSE UPPER LEFT AND CLEAR ON LLL.\nCARDIAC- HR 70'S NSR WITH RARE PVC. MAP MAINTAINED AROUND 65 ON LEVO AT 0-.04MCGS/KG/MIN. SHE IS PRESENTLY ON .02MCGS/KG/MIN.\nGI- ABD SOFT DISTENDED WITH POS BS. TF RESUMED VIA OGT TODAY. PROMOTE WITH FIBER AT 10CC/HR ADVANCED BY 10CC/HR Q 4 HOURS TO GOAL OF 60CC/HR. SHE IS PRESENTLY ON 20CC/HR WITH MINIMAL RESIDUALS. SHE HAD ONE MED SOFT BROWN GUIAC POS STOOL TODAY.\nGU- FOLEY PATENT DRAINING CLEAR YELLOW URINE AT 30-60CC/HR. SHE IS PRESENTLY 450CC POS. SPOKE WITH DR ABOUT THIS. GOAL IS EVEN TO 500CC POS FOR HER. IF SHE STARTS TO GET CLOSE TO 1 LITER POS WILL DIURESE HER.\nENDO- BS AT NOON 138. NOT REQUIRING SS. ON Q 6 HOUR FS.\nHEME- HCT 27.8 AFTER 1 U PRBC FOR HCT 25.3 LAST PM. REPEAT HCT PENDING FROM 1600 TODAY.\nID- TEMP MAX 100.1 DOWN TO 99.2 TODAY. CONT ON VANCO,LEVO AND AZOTRNAM.\n HUSBAND AND DAUGHTER IN TO VISIT. THEY WERE BOTH UPDATED BY THIS NURSE.\nPLAN- CHECK RESULTS OF HCT FROM 1600. WEAN LEVO TO OFF AS TOL. MONITOR FLUID STATUS WITH GOAL OF EVEN TO POS 500CC.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-02 00:00:00.000", "description": "Report", "row_id": 1319879, "text": "focus; addendum\nHEME- REPEAT 1600 HCT STABLE AT 27.3.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-02 00:00:00.000", "description": "Report", "row_id": 1319880, "text": "BS occ rhonchi; one albuterol NDI given without change in BS. Pt placed on PSV for 5 hr with NAD. Unable to get PSV below 10. Will attempt to wean PSV again tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-03 00:00:00.000", "description": "Report", "row_id": 1319881, "text": "Resp Care,\nPt. remains intubated on A/C . RSBI 133 this am. Attempted IPS , but RR 30's VT 200's. Now on IPS 10, RR 27, VT 300's. ABG this am acceptable. Plan to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-03 00:00:00.000", "description": "Report", "row_id": 1319882, "text": "CCU NPN: 1900-0700\n\nS: Able to communicate by writing, gesturing\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 60s-70s, SR, rare PVC. Continue to titrate Levophed for goal MAP 60-65 - attempted to discontinue pressor and MAP decreased to 50s within minutes - Dr. (CCU team) aware. Hct remains stable this AM at 26.9 (27.3).\n\nRESP: Initiated PSV this AM at 0430 - pt. tolerating CPAP+PS/ w/ ABG: 7.38/41/119/25/98%. Did not tolerate setting of as became tachypneic w/ inadequate tidal volumes. Prior to AM PS trial, pt. on AC/0.40/500/10/5 w/ latest ABG: 7.39/42/132/26/99%. Suctioned frequently for small-moderate yellowish secretions. Oral cavity suctioned for thick, yellow mucousal plugs. Improved RUL PNA per CXR.\n\nID: Low-grade temp - Tmax 100.0 PO. Remains on triple antibiotics - Vanco, Levofloxacin, Aztreonam. Skin clammy at times and warm to touch. WBC stable - 5.2 this AM (5.3).\nGI/GU/ENDO: Abd. soft, non-tender, non-distended. Scattered ecchymoses. OGT placement confirmed by auscultation. TF advanced as tolerated - held for one hour for residual > 100 -> currently tolerating TF at 40cc/hr. Residual undigested feeding w/ flecks of old blood - continues to be OB+. No BM this shift. Foley changed as previous cath noted to be leaking. UOP 20-70cc/hr, I/O: +835cc , +207cc . Further diuresis on hold at present per CCU team. FS required no sliding scale insulin coverage.\n\nNEURO: Anxious and restless at times - sedation transiently increased during night for rest - later decreased during PSV. Attempts to write, mouth words, gesture. MAE, +CSM. Pupils equal, brisk reactivity. Follows commands consistently. Requires emotional reassurance as pt. appears frustrated w/ ETT, coughing, suctioning etc.\n\nA/P: Multiple recent admissions for CHF exacerbation w/ known critical AS -> AVR on hold until resolution of ID issues. Wean Levophed w/ goal MAP > 65. New RUL PNA - improvement w/ triple antibiotics. PSV -> wean as tolerated. Advance TF as tolerated w/ GR 60cc/hr. Poss. colonoscopy prior to AVR to evaluate GIB? Emotional support to pt. and family.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-11 00:00:00.000", "description": "Report", "row_id": 1319911, "text": "CCU Nursing Progress Note 1900-0700\nS: \"All of these medications. Day after day\".\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: AAOx3. Pleasant and cooperative. MAE. PEARL. 3mm in size. Brisk in response. Denies pain. Requesting sleep aid. Received Klonipin 0.5 mg w/ good effect. Slept well w/ minimal interuption.\n\nCV: Hemodynamically stable. HR 70-82. Rare PVC. Experienced single episode around 0250 of accelerated junction/ ?AIVR for approx 15 seconds and then returned to NSR. No other change in rhythm . NIBP 92-125/39-50. MAPs 53-77. MAPs decreased w/ Lasix gtt titration. Goal SBP >90 and MAP ^50s-60. Metoprolol dose decreased from 37.5 to 12.5 mg po. Pt tolerated well. HCT stable at 28.6. Electrolytes stable. Distal pulses palpable.\n\nResp: LS coarse in apexes. Diminished bases L>R. Faint bibasilar rales. RR 19-22. O2 sats 96-99% on 4L supplemental O2 via NC. Cont to require HOB 45 degrees and sleeping with 3 pillows.\n\nGI/GU: Tolerating House diet per report. +BS x 4 quadrants. Abd obese. NTND. Transient episode of nausea but pt declined antiemetic. Cont on 1500 ml fluid restriction. F/C to gravity. No additional leaking from F/C. Lasix gtt titrated from 5-15 mg/hr to maximize UOP but weaned back to 10 mg/hr to maintain SBP>90 and MAP>60. UOP 40-160/hr. Minimal response to decreased Metolazone dose of 2.5 mg. At 0400 UOP decreased to 20cc/hr. HO notified. No additional intervention d/t marginal BP. Cont to follow. Goal was for pt to be negative 1L. Pt +337 as of MD. -65 since MD and remains -2L LOS. BUN/Cr 48/1.4 (1.2).\n\nID: Afebrile. Tmax 98.3 po. Completed 14d abx course. WBC slightly elevated this am 15.4 (11.3).\n\nSkin: Intact.\n\nEndo: BS 203-121. Required 4 units coverage per RISS last pm. No coverage indicated this am. Non- diabetic. Prednisone dc'd.\n\nSocial: No calls or visitors .\n\nA/P: 75 yo female awaiting AVR, afebrile and HD/resp status stable. Cont aggressive diuresis in preparation for surgery. Monitor BP/MAP in setting of diuresis. Monitor I/O. 1500 mL fluid restriction. Follow temp curve. Cont diuresis as tolerated. Cont to advance diet and activity as tolerated. Encourage CDB/ Inc spirometry exercises. Cont supportive care. Keep family updated in POC.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-10 00:00:00.000", "description": "Report", "row_id": 1319909, "text": "ccu npn 1900-0700\nS:\"My breathing is better today, I think.\"\nO: Please see carevue for VS and objective data\nCVS: Hemodynamically stable with HR 60-80's NSR, no vea noted, K+ 4.1- 3.6, repleted with 40meq IV KCL. Lopressor increased to 37.5mg po TID. BP ranges via right radial aline initially 120-150's/50-80. aline positional, difficult to draw blood from at change of shift, unable to draw blood later in shift, despite manually flushing and intermittent waveform. CCU intern aware. SBP dropped to 80's-90's/40 after po meds in evening and continued Lasix drip. CCU team notified, Lasix drip held overnight with total I/O NEG. 1700cc at MN. Given 250cc NS bolusx2 with effect to maintain SBP>90.\nResp; Initially on 5L n/c with sats 95-97%, abg 80/46/7.47/34/8 97%, Pt. requested cool neb from RT, placed on 50% cool neb via FT. Sats 92-100%, unable to repeat abg from aline as above. Initially on IV Lasix drip at 20mg/hour with the addition of po Zaroxyln. U/O 160-190cc/hour, Total I/O as above, Lasix drip held overnight in setting of hypotension as ordered.\nGI:GU: Taking po's/meds, no N/V. Abdomen soft, large with active bowel sounds, no stool. Foley to drainage, leaking large amounts of urine, despite 10cc in balloon, therefore foley changed 18Fr. Draining clear, yellow urine.\nID: afebrile on IV antibxs as ordered.\nNeuro: Pt. A/A/Ox3, pleasant and cooperative, enjoyed being up to chair most of day, slept well after Clonazepam 0.5mg as ordered. Only given 1mg IV Morphine with mild anxiety and tachypnea with foley change with good effect.\nA: overdiuresis in setting of severe AS, requiring NS bolus for SBP.\nP: Cont. to monitor hemodynamics, maintain SBP>90. Aline to be dc'd or new with plan on am rounds, follow up with am labs. Cont to monitor resp. status, cont antibxs as ordered. Awaiting AVR. Comfort and emotinal support to Pt. and family\n" }, { "category": "Nursing/other", "chartdate": "2152-04-10 00:00:00.000", "description": "Report", "row_id": 1319910, "text": "CCU NPN 7a-7p\nS: \"I feel great today.\"\nO: please see carevue and ICU update for complete assessment data\nNo events\nNEURO: rare c/o oral pain, relieved w/ elixer, otherwise no c/o pain. , A&Ox3, easy 1 assist OOB->chiar, remained in bed all day. PT consulted for tomorrow.\n\nCV: HD stable, lasix gtt on briefly but very pronounced diuresis after 5mg metolazone, lasix gtt currently off, titrating to huo 50cc/hr. Also w/ 1L PO fluid restriction instituted. MAP > 60, HR NSR w/ rare PVC, pm lytes pending. Feet cool, palp pulses.\n\nRESP: LS coarse, clearing t/o day, faint rales @ bases bilaterally, dim L>R. (+) congested nonproductive cough. O2 weaned to 4L NC, maintaining Spo2 >98%, NAD, RR 20s. Aline d/c'd no no further ABGs drawn as pt has had no resp distress\n\nGI: tol heart healthy diet, no dysphagia. Small BM in am, trace OB (+). Cont bowel regimen. Abd soft, obese, nontender.\n\nGU: Foley draining CYU, excellent response to diuresis. Decreasing metolazone to 2.5mg . Goal -1l or huo -50cc.\n\nENDO: restarted RISS as needed. Prednisone d/c'd w/ subjective improvement in gout symptoms.\n\nID: off all abx today (completed 14 day course). Remains afebrile.\n\nSKIN: Aline d/c'd. PIV x 2, PICC. No breakdown noted.\n\nSOC: husband in to visit, very supportive and encouraged by pts condition.\n\nA: 75yo awaiting AVR; afebrile, HD and resp stable.\nP: monitor u/o, lasix gtt if needed to maintain hourly fluid balance -50cc, goal -1L. Monitor BP w/ diuresis. Encourage activity and diet as tolerated. Monitor temp spike off abx. Encourage TCDB. Support to pt and family as needed.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-01 00:00:00.000", "description": "Report", "row_id": 1319875, "text": "CCU NPN 0700-1900\n\nS/O: PLEASE SEE CAREVUE FOR COMPLETE OBJ DATA. PT ANSWERING QUESTION BY NODDING HEAD, DENIES PAIN.\n\nMS: DAILY WAKE UP W/ CHANGING CORDIS TO TLC, RESPONSIVE TO VOICE, SPONTANEOUS EYE OPENING. DENIES PAIN, ALTHOUGH NON-VERBAL CUES INCLUDE, + GRIMACE, INCREASED RR, INCREASED BP, + GAGGING ON ET TUBE AND COUGHING, INCREASED HR. BOLUSED W/ 1MG VERSED, AND 50MCQ FENTANYL W/ + EFFECT. SEDATION AT .5MG/25 MCQS VERSED/FENTANYL.\n\nCV: HCT DROP TO 25.3, PLAN TO TRANSFUSE 1UNIT PRBC W/ 40MG IV LASIX.\nLAST CO/CI/SVR = 5.3/2.72/740. SWAN PULLED THIS SHIFT, AND CORDIS CHANGED TO TLC OVER WIRE. TLC OK TO USE BY CXR. REMAINS DEPENDENT ON LEVOPHED, NOW ON .04MCQ/KG/MIN. BP 120/35/60 AT REST.\n\nRESP: LAST ABG AT 1630 ACCEPTABLE, SEE CAREVUE. RISBI DONE ON ROUNDS= 95. LSCTA AFTER SXN'ING. SXN'ING APROX Q2-3HRS MOD AMOUNTS OF YELLOW/TAN SPUTUM. REMAINS ON VENT SETTINGS AC .40/500/5.\n\nGI/GU: OGT TO LWIS W/ + GROSSLY POS OUTPUT. CLAMPED FOR PO MEDS, SENNA, COLACE, GIVEN, NO BM. HYPOACTIVE BS. OGT ASPIRATE SCANT THIS AFTER NOON, OGT LEFT CLAMPED. PPI . LASIX DOSING CONTINUES, MIN RESPONSE TO 7AM DOSE. U/O >40CC/HR.\n\nID; VANCO LEVEL 14.8 AT TROUGH, DOSED THIS AM. REMAINS ON LEVOFLOXACIN, AND AZTREONEM. AFEBRILE, NO TACHYCARDIA. SWAN TIP SENT FOR CX.\n\nLYTES/ENDO/SKIN: REPLETED W/ 1GM CALCIUM GLUCONATE, 2GM MAG SULFATE. BS WNL > 140 NO INSULIN, SKIN INTACT.\n\nSOCIAL: HUSBAND AND DTR IN TODAY.\n\nA/P: LEVOPHED DEPENDENT, AFEBRILE ON TRIPLE ABX, RESP STABLE ON AC SETTINGS, +HCT DROP. NEW TLC, RIJ SITE.\nWEAN LEVO IF TOLERATED, TITRATE SEDATION, IV ABX, SXN AS NEEDED, TRANFUSE 1UPRBC THIS EVE, FOLLOW CX'S.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-02 00:00:00.000", "description": "Report", "row_id": 1319876, "text": "Resp Care,\nPt. remains intubated on A/C . No vent changes this shift. Albuterol MDI started for wheezes. ABG acceptable. RSBI 119 this am. Maintain current vent settings.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-08 00:00:00.000", "description": "Report", "row_id": 1319901, "text": "0600 event note.\nafter pt was toileted on Bed pan, she became rather SOB. pt has been experiencing activity intolerance post repositioning, but now RR up to 30, face ruddy red, dim lung sounds. albuterol neb given by respiratory. pt further declined, RR up to 30, improved lung sounds after abuterol, but stlii struggling. ABG drawn, pt placed on bipap, md paged. here to see pt.\n RN\n" }, { "category": "Nursing/other", "chartdate": "2152-04-08 00:00:00.000", "description": "Report", "row_id": 1319902, "text": "NPN 7PM-7AM\ns: \"Can I have more oxygen?\"\nO: please see careview for vitals and objective data\npt with Aortic stenosis, CHF, PNA, and new a fib, has been struggling with a marginal respiratory status since extubation.she has been on and off Bipap last few days.\nNeuro: intact, OX3 moves all extrem.\nCV: pt has new onset afib, discovered at change of shift, ventricular response 110-130. pt was given lopressor with poor effect, we also gave two doses of cardizem, 10 mg ivp, and amiodarone 1mg min ( no bolus dose) and at 0330 am pt converted to sinus. Sr now rate 71-90\noccasional PVC's. pt has had episodes of pulmonary edema, tx'd with lasix, however team feels she has reached euvolemia, no lasix this shift. pt is waiting for surgery to schedule her for AVR.\nRepiratory: pt was doing well early in the shift, however she has\nsevere activity intolerance. Pt was maintained on 50 afm and 4l nc, with o2 sats 95-97 percent. when she was turned, she would become rather sob, ruddy complection, o2 sat still ok, 93-96 but wheezy and rr would climb to 30's. she would recover after ten minutes rest.\nat 0600 however, after being on the bedpan and cleaned up, pt became very sob, dim lung sounds ant with exp wheezes, RR 30 skin color poor.\nwe gave albuterol neb, drew an ABG, and placed pt back on BIpap. Intern now at .\nAfter 10-15 minutes on Bipap, pt has improved. Now RR down to 28, o2 sats up to 99, color wnl, and lungs sound mostly clear anteriorly,\nsome rhonchi.\nGI: pt eating puree foods. Had very small BM after bisacodyl supp, slightly guiac positive.\nGU - foley patent, putting out 20-40 cc per hour. pt co burning, lidocaine jelly x 1.\nSkin: no breakdown\nLines: pt has new L ac picc line, all other lines dc'd except for aline. Md did request that a line be removed after AM labs, however, We may need another stat gas.\nID afebrile, continues on ABT.\nA: pt with aortic stenosis, awaiting surgery, pna chf, a fib, now in SR. pt has severe activity intolerance and is back on BIpap. she has not improved much since extubation, and may need to be reintubated.\np: continue to follow lab, abg. follow respiratory status, pt may require albuterol tx, ? additional lasix. currently on Bipap. Follow rhythm, decrease amiodarone to 0.5 mg/min x 18 hours. reassure pt, and keep pt and family updated on POC as discussed in multidiciplanary rounds.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-08 00:00:00.000", "description": "Report", "row_id": 1319903, "text": "Respiratory Care Note:\n Patient continues to need intermittent mask BIPAP t/o the day. Bs coarse with scattered exp wheezing. Received alb/atro med nebs with fair effect. Cough loose, and non-productive on request. Patient giving good effort in tolerating mask vent. See Carevue flowsheet for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-08 00:00:00.000", "description": "Report", "row_id": 1319904, "text": "PT C AS AWAITING VALVE REPLACEMENT ,HAS CHF,PNA ON AND OFF BIPAP SINCE EXTUBATION PAST SEVERAL DAYS\n\nNSR SINCE 330 AM WHEN SHE CONVERTED FROM AFIB P AMNIODERONE.CURRENTLY ON DRIP .5MG TILL AM.BP STABLE .\n\nON BIPAP MOST OF DAY,OFF X2 FOR 1 HR EACH.CO SOB,GETS IV MSO4,NEB AS WELL .\n\nHAD BOOST PUDDING AND RESOURCE DRINK.SOFT STOOL THIS AM .CO PAIN IN MOUTH,LIDOCAINE MOUTH WASH TO C RELIEF .\n\nLASIX DRIP INCREASED TO KEEP HUO OVER 100CC\n\nPT ALERT,ORIENTED ,COOPERATIVE .CO PAIN IN L RING FINGER,RED, SWOLLEN.HO AWARE .\n\nPT C MARGINAL RESP STATUS AWAITING SX\n\nFOLLOW FLD STAUS ON LASIX DRIP\nENCOURAGE HIGH CALORIE INTAKE WITHIN CONSRAINTS CAUSED BY BIPAP DEPENDENCE .\n" }, { "category": "Nursing/other", "chartdate": "2152-04-09 00:00:00.000", "description": "Report", "row_id": 1319905, "text": "CCU NPN 1900-0700\nS: \" How does my breathing look to you...they say I'm getting better but I use that tight mask more.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 82-90's NSR, rare PVC's noted, ABP 114-144/43-56 Maps >70. Pt continues on amiodarone 0.5 mg/min as ordered, amio gtt to be dc'd this am during rounds per Dr. . Pt remains NSR-HR increasing in 90's and SBP's 140's-160's with anxiety. Bilateral pedal pulses palp, pt tol 25 mg metoprolol. At approx midnoc K 3.6, mg 1.9-> mg repleted with 2 grams mag sulfate, awaiting K repletion as pt has 1 port for abx/electrolytes available on PICC.\n\nResp: Received pt on mask ventilation, please see careview for all vent/O2 settings and ABGs, CPAP+PS 60% with tidal volumes 400's, RR 26-32, O2 sats 96-100%. Pt switched over to face tent 11L 70% at approx 2200 so pt could take PO meds, pt given 2 mg IV morphine-> pt tol face tent for approx 2 hours, pt verbalizing anxiety, pt noted to for increased use of accessory muscles, HR and BP increasing-> Pt given 0.5 mg PO ativan and 0.5 mg IV ativan and pt placed back on mask ventilation-ABG pending. LS coarse to rhonchi at apices and coarse to crackles at bases.\n\nNeuro: Pt alert and oriented x 3, asking appropriate questions regarding care, MAE, pupils 4 mm brisk reactive. Pt with c/o R ring finger pain, joint red, swollen, painful to touch-CCU intern and resident in to eval-> pt given 40 mg prednisone(to be given x 4 days).\n\nGI/GU: Pt abd soft, + BS x 4, no stool this shift. Pt tol meds crushed in pudding, sips of water with no coughing noted. Pt continues on lasix gtt->gtt weaned from 15 mg/hr to 12 mg/hr for goal u/o >100CC/hr, please see flowsheet for u/o-pt -670 cc at midnoc.\n\nID: T max 99.8 rectal, HO aware.\n\nA/P: 75 y/o female awaiting AVR, with CHF, PNA , continues on mask ventilation/face tent, diuresing with lasix gtt, morphine sulfate and ativan given with some decrease in resp workload and anxiety. Continue to monitor pt hemodynamics-amio gtt to be off this am in rounds and start PO in am, monitor resp status, ABGS-continue with nebs. Continue to monitor u/o, titrate lasix gtt as tol, monitor temps. Continue to provide emotional support to pt, admin meds for anxiety as ordered and pt tol, awaiting further POC per CCU Team.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-09 00:00:00.000", "description": "Report", "row_id": 1319906, "text": "Resp: pt on FFV PSV 10/5/60%, then placed on 60% f/t for about 3 hrs. HHN administered Alb/Atr with no adverse reactions. Bs are coarse with occasional exp wheeze noted. Pt placed back on FFV PSV 10/5/50% due to ^ wob. Pt tolerating mask, 02 sats @ 100%. Will continue to wean to f/t as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-09 00:00:00.000", "description": "Report", "row_id": 1319907, "text": "75 YR OLD AWAITING AVR C PNA,CHF.TODAY FIRST DAY OFF BIPAP SINCE EXTUBATION SEVERAL DAYS AGO .\n\nSR NO RUNS OF AFIB SINCE 2/t 3 AM .AMNIODERONE DRIP DC,ON PO.LOPRESSER INCREASED.BP TOL MEDS.\n\nSAT >95 ON 5L .NOT ASKING FOR BIPAP .ON NEBS ,C/R.BS DIMINISHED .\n\nTAKING PUREED DIET .NO STOOL,POS BS .\n\nON 20 MG IV LASIX/HR ,HUO 100 TO 200 .NEG 1500 .\n\nAFEBRILE ,ON ANTIBX .\n\nSOB MUCH IMPROVED .AWAITING SX ,AVR HOPEFULLY THIS WEEK.\n\nPT LESS ANXIOUS .OOB TO CHAIR MOST OF DAY.CLONIPIN DOSE ORDERED .\n\nMONITOR FLUID BALANCE\nBIPAP FOR SOB\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-09 00:00:00.000", "description": "Report", "row_id": 1319908, "text": "Respiratory Care Note:\n Patient off mask bipap since 0800 this am. BS much improved. She appears comfortable on nasal O2. See Carevue flowsheet for details. Plan to monitor and provide bipap as needed.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-07 00:00:00.000", "description": "Report", "row_id": 1319898, "text": "CCU NPN: 1900-0700\n\nS: \"I feel better now ...\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 70s-90s, SR w/ occ. PACs and PVCs. HR increased to 100s during episode of resp. distress and returned to baseline after initiation of mask-ventilation. SBP also increased to 160s during resp. distress and resolved w/ rest on BiPAP. PM lytes repleted as ordered. AM Hct stable: 27.2 (28.0).\n\nRESP: Received pt. in the midst of episode of resp. distress - CXR consistent w/ flash pulm. edema and pt. was adm. 60mg Lasix IVP and Albuterol/Atrovent neb. Initial ABG at : 7.35/55/225/32/99% which prompted use of mask ventilation -> placed on BiPAP for 2.5 hours and resp. status improved. ABG improved to 7.44/40/154/28/99% and pt. switched to 2-4L NC and humidified shovel mask w/ AM ABG: 7.47/46/98/34/98%. Lung fields coarse throughout w/ crackles and exp. wheezes present. Maintained O2 sat > 95% throughout episode.\n\nGI/GU: Abd. soft, non-tender, non-distended. BS active x 4 quadrants. Abdominal ecchymoses continues. Tolerated sips of water throughout shift, otherwise, no PO intake. Impressive diuresis within hour after administration of Lasix, however, tapers off thereafter (CCU team aware). UOP 32-360cc/hr, I/O: -150cc , -600cc thus far. Renal function remains stable.\n\nNEURO: Alert and oriented x3. Pleasant and cooperative, anxious at times - emotional reassurance given. MAE, +CSM.\nA/P: Adm. to OSH w/ CHF exacerbation requiring intubation -> transferred to as pt. scheduled for AVR . Found to have CHF and RUL PNA - treated w/ triple antibiotics and diuresis. Post-extubation (), pt. w/ tenuous resp. status; episodes of flash pulm. edema. Continue to follow resp. status closely, diuresis as needed. Emotional support and reassurance to pt. Awaiting further plans from team.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-07 00:00:00.000", "description": "Report", "row_id": 1319899, "text": "resp care\nPt placed on mask ventilation for an epsode of severe resp distress. Pt placed on 10psv/5peep and 60%. ABG and wob both improved. Pt placed back on 4lcan/50%FT.Will cont to follow and use bipap as needed.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-07 00:00:00.000", "description": "Report", "row_id": 1319900, "text": "Nurses Note 7a-7p\nS: \"My breathing's a little better\".\nO: See careview for all objective data.\nNeuro- A+Ox3, cooperative with care. PEARL/MAE in bed, no c/o sob/cp.\nPRN ativan 1mg given for anxiety.\nResp- LS coarse throughout, conts on 50% face tent and 3L nc with sats 93-99%. RR 22-36, no flashing episodes this shift. Diuresed x1 with 60 iv lasix, uop 400cc in 1hr. Goal of 1L neg was met, no further lasix given. PRN Ms04 2mg given x1 with fair effect. Nebs given q4-6.\nCV- Tele SR/ST occ PVCs, HR tachy 92-130s. ABPs 120s-140s, given 5mg iv lopressor x2 with fair effect.\nGI/GU- Abd soft/distended, +bs no bm. Tol pureed diet. Foley patent, uop 20-50cc/hr.\nID- Afeb, TLCL removed, A-line to be pulled. Both lines >10 days old.\nPt had PICC place in by iv RN, CXR confirmed placement.\nSkin- Intact, no issues.\nA/P: 75yo female with CHF exacerbation, R UL PNA tx with triple abx. Several episodes of flash pulmonary edema tx with BIPAP lasix/\nlopressor/Ms04. Pending AVR ? next week. Cont to monitor resp/\nhemodynamic status. Support Pt/family.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-01 00:00:00.000", "description": "Report", "row_id": 1319873, "text": "CCU NPN: 1900-0700\n\nS: Writing, mouthing words - able to make needs known\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 60s-70s, SR w/ occ. PVCs. Levophed titrated to maintain MAP > 60. PADs 14-25, PCWP 24-22 w/ slight improvement after diuresis. CVP 6-10. Hyperdynamic w/ latest: 6.4/3.28/650. Hct remains stable - AM: 26.6.\n\nRESP: Remains intubated on AC/0.40/500/10/5, latest ABG: 7.33/46/111/25/98%. O2 sat > 95%. Suctioned frequently for moderate amounts of white-yellow, thick secretions (ETT and oral). Diminished breath sounds. CXR consistent w/ RUL PNA.\n\nID: Febrile on initial assessment - pancultured. Adm. Tylenol in previous shift w/ positive results as Tmax 100.6 core and Tcurrent 99.2 core. Triple antibiotic coverage - Vanco/Levofloxacin/Aztreonam. AM random Vanco pending. WBC 5.5 this AM.\n\nGI/GU/ENDO: Abd. soft, distended, non-tender. Hypoactive bowel sounds. Abdominal hernia evident w/ pt. coughing. OGT placement confirmed by auscultation - aspirates cont. to be dark red blood (brown) -> OB+. LC and LIS applied throughout shift. No stool. Adequate UOP w/ positive response to Lasix -> hourly UOP 34-190cc. I/O: -570cc . FS covered as indicated per sliding scale.\n\nNEURO: Anxious at times prompting increase in sedation during night. Easily to voice - follows commands consistently and able to make needs known w/ written communication and gestures. Soft wrist restraints applied for safety - pt. frequently reaches for ETT.\n\nA/P: CHF exacerbation vs. PNA w/ severe AS awaiting AVR once ID issues resolved. Recent temp spike - triple antibiotic coverage initiated . Cultures pending. Remains Levo dependent - titrated to MAP > 60. PADs slightly increased w/ diuresis, hyperdynamic consistent w/ sepsis? New UGIB -> NPO, poss. EGD ? Anxious - cont. emotional support to pt. and family.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-05 00:00:00.000", "description": "Report", "row_id": 1319894, "text": "NPN 0700-1900\n75 yo woman with severe AS, CHF, and PNA. Extubated then on BiPap. Today taken off of BiPap, tolerating shovel mask 70 FiO2. Awaiting AV replacement.\n\nS: \"can I have some Jello?\"\n\nO: Please see careview for vitals and other objective data.\n\nCV: Remains in NSR, HR 70's-80's, occ 90's when anxious. ABP 120's-130's/40's. Lopressor 5mg IV Q4 hrs.\n\nResp: Bipap removed, pt on shovel mask 70 FiO2, SpO2 96-100%, RR 20-30. Lung sounds crackles throughout, intermittent scattered expiratory wheezes, tx'd with IV Lasix, Albuterol and ATR Nebs. CXR done this morning showed PNA slightly improved. Following ABG's.\n\nNeuro: Pt alert and oriented, , pt moves all extremities, follows commands appropriately. Seems withdrawn, CCU team aware to f/u w/ ? antidepressant\n\nGI: Abd soft, Bowel sounds present. One medium hard brown stool during shift, Heme+. NPO for now, she has been sipping water, tol PO meds.\n\nGU: Responding to lasix with 600+ cc of urine. Foley draining clear yellow urine.\n\nSkin: remains intact.\n\nID: Tmax 97.5, cont IV anitbiotics for PNA.\n\nSoc: Husband and daughter in to visit today aware of plan by MD.\n\nA: Pt with CHF, AV Stenosis, PNA, awaiting AV replacement. HD stable, tenuous resp sts on/off BiPap s/p extubation.\n\nP: As discussed on multidiciplinary rounds cont to monitor resp and cardiac status, Follow ABG's. Cont bowel regimen. Support Pt and family as indicated.\nWritten by: \nCosigned by , RN\n" }, { "category": "Nursing/other", "chartdate": "2152-04-05 00:00:00.000", "description": "Report", "row_id": 1319895, "text": "Resp Care\n Pt remains on cool aeorsol face tent. Pt was on NIVV for most of the morning, but tolerated well for the rest of the day without NIV. Plan is to continue monitoring Pt and place NIV back on if needed. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2152-04-06 00:00:00.000", "description": "Report", "row_id": 1319896, "text": "CCU NPN: 1900-0700\n\nS: \"I guess I'm doing okay ...\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 80s-90s, SR/ST w/ occ. PVCs. BP stable -> SBP increased to 150s w/ episode of resp. distress, treated w/ 5mg Metoprolol IV (which pt. continues to receive q4h as ordered). MAP > 65. PM lytes repleted as ordered. Hct stable this AM at 28.0 (27.5).\n\nRESP: Experienced episode of respiratory distress at 2245 during which pt. became acutely tachypneic, hypertensive and anxious. Treated w/ Metoprolol 5mg IVP, 60mg Lasix IVP and Albuterol/Atrovent neb. Positive response to above action and pt.'s respiratory distress resolved within 10 minutes. ABG at that time was: 7.37/52/183/3/31 -> as O2 sats returned to baseline (95-100%) and pt. w/ no further c/o SOB, decision made w/ CCU team to continue face tent and nasal cannula for oxygenation and hold on further BiPAP. Pt. continued to tolerate face tent (FiO2 weaned from 0.70 -> 0.50) and 2L NC w/ AM ABG: 7.43/45/88/31/97%. Additional nebulizer treatment adm. for continued insp/exp upper airway wheezing w/ positive results. RR 21-28.\n\nGI/GU: Abd. soft, non-tender, non-distended. Ecchymotic in abdominal area. BS active x4 quadrants. NPO at present although pt. tolerated small sips of water and ice chips. Small, liquid BM smear. Positive response to Lasix (60mg Lasix IVP adm. at 2250) w/ UOP 30-220cc/hr. I/O: -620cc and -485cc thus far. (Goal: -500 to 1L/day.)\n\nID: Afebrile. Tmax 98.4 PO. Continues on triple antibiotics. Has weak, non-productive cough - encouraged ICS use.\n\nNEURO/SOCIAL: Lethargic, oriented x3. Pleasant and cooperative but appears somewhat withdrawn. Asking appropriate questions re: plan of care. MAE, +CSM. Son visiting in evening.\n\nA/P: Admitted to OSH for CHF exacerbation -> required intubation and was transferred to as pt. scheduled for AVR . Found to have CHF and RUL PNA - treated w/ diuresis and triple antibiotics. Extubated c/b episodes of flash pulm. edema. Resp. status continues to be tenuous - follow ABGs, volume status closely. Plan for poss. AVR in near future as ID issues resolve. Emotional support to pt. and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-06 00:00:00.000", "description": "Report", "row_id": 1319897, "text": "Nursing Note 7a-7p\nS: \"I can't catch my breath\".\nO: See careview for all objective data.\nResp/CV- Remained on 50% face tent/2L nc with sats >96%. ABG 7.43 45 90 4 31. Pt was doing fine until approx 1800 when she c/o feeling sob. Became tachypnic/tachycardic, RR 30-36, HR to 130s with SBPs 180-210. HO made aware who came and saw pt. Ordered for 5mg iv lopressor/60mg iv lasix and 2mg iv Ms04. NC ^ 4L, face tent @ 100%. RR reduced into 20s, HR 98-104, SBPs 145-155. Stat CXR done, ABG sent->pending.\nGI/ Pt tol pureed diet well, speech/swallow eval canceled. Abd soft/distended +bs no stool. Foley patent, voiding qs cyu and diuresing on lasix.\nSkin- Intact, no breaks/abrasions.\nA/P: 75yo female with CHF exacerbation, R UL PNA on triple abx. Pending an AVR next month. Episode of flash pulmonary edema tx with lopressor/lasix/Ms04, ? BIPAP. Cont to monitor pulmonary status.\n\n" }, { "category": "Nursing/other", "chartdate": "2152-04-01 00:00:00.000", "description": "Report", "row_id": 1319874, "text": "BS CTAB. Sx'd mod amts thick pale yellow mucus. No vent changes in presence of new UGIB and continued element of CHF.\n" }, { "category": "ECG", "chartdate": "2152-04-18 00:00:00.000", "description": "Report", "row_id": 203221, "text": "Sinus rhythm and intrinsic A-V conduction with inappropriate pacemaker artifact\nwithout capture. Intraventricular conduction delay. Frequent atrial ectopy.\nThese findings are new as compared to the previous tracing of . Clinical\ncorrelation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2152-04-13 00:00:00.000", "description": "Report", "row_id": 203222, "text": "Normal sinus rhythm, rate 99. Left ventricular hypertrophy. Borderline first\ndegree A-V block. Non-specific inferolateral repolarization changes consistent\nwith left ventricular hypertrophy and/or ischemia. Compared to the previous\ntracing of the sinus rate is faster.\n\n" }, { "category": "ECG", "chartdate": "2152-04-12 00:00:00.000", "description": "Report", "row_id": 203223, "text": "Normal sinus rhythm, rate 73. Probable left ventricular hypertrophy.\nNon-specific generalized repolarization changes compatible with left\nventricular hypertrophy and/or ischemia. Q-T interval prolongation. Borderline\nfirst degree A-V block. Borderline left atrial abnormality. Compared to the\nprevious tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2152-04-08 00:00:00.000", "description": "Report", "row_id": 203224, "text": "Compared to the previous tracing of atrial fibrillation has given way to normal\nsinus rhythm. Non-specific repolarization changes persist.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2152-04-07 00:00:00.000", "description": "Report", "row_id": 203225, "text": "Atrial fibrillation with a rapid ventricular response of approximately\n120 beats per minute. Generalized non-specific repolarization changes. Compared\nto the previous tracing of normal sinus rhythm, rate 86 has given way\nto atrial fibrillation with a rapid ventricular response.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2152-04-06 00:00:00.000", "description": "Report", "row_id": 203226, "text": "Sinus rhythm. T waves flattening in the limb leads with slight ST segment\nelevations in leads V1-V3. Biphasic T waves and inverted T waves in leads V4-V6\n- consider myocardial ischemia. Compared to the previous tracing of the\nQRS voltage has decreased and the lateral T wave inversions are less\npronounced.\n\n" }, { "category": "ECG", "chartdate": "2152-04-05 00:00:00.000", "description": "Report", "row_id": 203227, "text": "Sinus rhythm\nProbable left ventricular hypertrophy\nDiffuse ST-T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nSince previous tracing of , sinus tachycardia absent and ST-T wave\nchanges less prominent\n\n\n" }, { "category": "ECG", "chartdate": "2152-04-04 00:00:00.000", "description": "Report", "row_id": 203456, "text": "Baseline artifact\nSinus tachycardia\nConsider left ventricular hypertrophy\nDiffuse ST-T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nSince previous tracing of , sinus tachycardia and further ST-T wave\nchanges present\n\n" }, { "category": "ECG", "chartdate": "2152-04-01 00:00:00.000", "description": "Report", "row_id": 203457, "text": "Sinus arrhythmia\nExtensive ST-T changes may be due to myocardial ischemia\nSince previous tracing, right bundle branch block resolved and diffuse T wave\nchanges new - consider ischemia\n\n" }, { "category": "ECG", "chartdate": "2152-03-30 00:00:00.000", "description": "Report", "row_id": 203458, "text": "Sinus tachycardia with 1st degree A-V block\nRight bundle branch block\nNonspecific ST-T wave changes\nQRS .12\nSince previous tracing, sinus tachycardia present\n\n" }, { "category": "ECG", "chartdate": "2152-03-30 00:00:00.000", "description": "Report", "row_id": 203459, "text": "Sinus rhythm\nRight bundle branch block\nSince previous tracing, sinus tachycardia absent\n\n" }, { "category": "ECG", "chartdate": "2152-03-29 00:00:00.000", "description": "Report", "row_id": 203460, "text": "Sinus arrhythmia\nST-T changes are nonspecific\nSince previous tracing, sinus arrhythmia present\n\n" }, { "category": "ECG", "chartdate": "2152-03-28 00:00:00.000", "description": "Report", "row_id": 203461, "text": "Sinus rhythm.\nNonspecific extensive ST-T changes may be due to myocardial ischemia\nSince last ECG, shorter PR interval, ST-T wave changes\n\n" }, { "category": "Radiology", "chartdate": "2152-03-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 905770, "text": " 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate placement of PA catheter\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, now intubated and febrile\n\n REASON FOR THIS EXAMINATION:\n Evaluate placement of PA catheter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Critical aortic stenosis, now intubated and febrile, PA catheter\n placed.\n\n COMPARISON: .\n\n FINDINGS: ET tube, right internal jugular central venous catheter containing\n Swan, NG tube, and right upper quadrant surgical clips are unchanged. The\n heart remains mild-to-moderately enlarged and the mediastinal contours are\n unchanged. Lung volumes have improved, but there are moderate-sized bilateral\n layering pleural effusions now. Pulmonary edema persists, mild-to-moderate.\n There is no pneumothorax.\n\n IMPRESSION: Mild-to-moderate CHF with effusions.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 906137, "text": " 2:25 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: check line placement\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, now intubated and febrile with PA\n line in place, with persistent fevers, ?pna, s/p changing cordis for TLC\n\n REASON FOR THIS EXAMINATION:\n check line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 75-year-old woman with persistent fevers, possible pneumonia.\n Evaluate for right IJ line placement.\n\n COMPARISON: Study from at 07:39.\n\n PORTABLE AP CHEST RADIOGRAPH: Again, seen is an ET tube and NG tube,\n unchanged in position. There has been interval removal of a right Swan-Ganz\n catheter. The tip of a right IJ catheter is seen at the cavoatrial junction.\n No pneumothorax is seen. The appearance of the cardiac and mediastinal\n contours is stable in appearance. Again seen is a pneumonia in the right\n upper lobe in perihilar region. There is a small left pleural effusion. The\n remainder of studies now significantly change in comparison to prior exam.\n\n IMPRESSION: Interval removal of a right-sided Swan-Ganz catheter, with the\n right IJ catheter tip positioned at the cavoatrial junction.\n\n" }, { "category": "Radiology", "chartdate": "2152-03-28 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 905495, "text": " 3:37 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate placement of swan-ganz catheter.\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, now intubated and febrile\n REASON FOR THIS EXAMINATION:\n Evaluate placement of swan-ganz catheter.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE-VIEW PORTABLE\n\n INDICATION: 75-year-old woman with critical AS.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared\n with the previous study of 5:18 a.m.\n\n The tip of the endotracheal tube is identified 3 cm above the carina. The\n right jugular Swan-Ganz catheter terminates in the main PA. A nasogastric\n tube terminates in the gastric fundus. No pneumothorax is identified.\n\n The previously identified congestive heart failure has been improving. There\n is continued patchy atelectasis in the left lower lobe. The heart is normal\n in size.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906199, "text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval of pna\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, now intubated and febrile with PA\n line in place, with persistent fevers, ?pna\n REASON FOR THIS EXAMINATION:\n eval of pna\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: .\n\n INDICATION: Fever.\n\n Lines and tubes are in satisfactory position. The cardiac silhouette is upper\n limits of normal in size. There has been interval resolution of vascular\n engorgement and perihilar haziness suggesting improved fluid status of the\n patient. Right upper lobe, and right perihilar consolidation also appears\n slightly better, and there is improving aeration in the left retrocardiac\n region as well. Left pleural effusion has apparently resolved. A small right\n pleural effusion is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 905622, "text": " 11:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate placement of PA catheter\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, now intubated and febrile\n REASON FOR THIS EXAMINATION:\n Evaluate placement of PA catheter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Critical aortic stenosis, now intubated and febrile.\n\n Portable AP chest. ET tube and Swan-Ganz and NG tube are unchanged.\n Cardiomediastinal silhouette is stable compared to the prior radiograph\n obtained yesterday. Left-sided effusion and pulmonary edema are unchanged.\n\n IMPRESSION: No short interval change.\n\n" }, { "category": "Radiology", "chartdate": "2152-03-29 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 905697, "text": " 4:39 PM\n PORTABLE ABDOMEN Clip # \n Reason: ogt placement\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with\n REASON FOR THIS EXAMINATION:\n ogt placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old female with OG tube placement.\n\n No prior studies for comparison.\n\n PORTABLE ABDOMEN: An orogastric tube is seen with its tip in an air-filled,\n nondistended stomach. Feces and air are seen in the ascending colon. The\n osseous structures are unremarkable.\n\n IMPRESSION:\n OG tube with tip lying within the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906277, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, now intubated and febrile, with\n persistent fevers, ?pna, RIJ in place, vented\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old female with critical AS, now intubated and febrile.\n\n COMPARISON: Comparison is made to serial chest radiographs dated to the most recent of .\n\n FINDINGS: Lines and tubes remain unchanged in satisfactory positions. The\n mediastinal and hilar contours are stable. There has been no interval change\n in a right upper lobe and right perihilar consolidation. There is a new small\n left pleural effusion and unchanged appearance of left retrocardiac\n opacification. No pneumothorax is identified. There is new mild vascular\n engorgement and perihilar haziness. A small right pleural effusion is\n unchanged.\n\n IMPRESSION: Persistent pneumonia. New mild volume overload.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 906161, "text": " 7:44 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: evaluate line placement\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, now intubated and febrile with PA\n line in place, with persistent fevers, ?pna, s/p changing cordis for TLC,\n line now pulled back 2 cm\n REASON FOR THIS EXAMINATION:\n evaluate line placement\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE CHEST OF , 20:02.\n\n COMPARISON: Previous study of , at 14:48.\n\n INDICATION: Central line placement.\n\n A right internal jugular vascular catheter is present, with the tip\n terminating in the region of the junction of the superior vena cava and right\n atrium. There is no pneumothorax. Multifocal areas of consolidation in the\n right upper lobe, right perihilar region and left lower lobe are without\n change. There also appears to be a component of congestive heart failure\n present with vascular engorgement and perihilar haziness. Small pleural\n effusions are noted.\n\n IMPRESSION: Central venous catheter terminates at junction of superior vena\n cava and right atrium, with no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907216, "text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o CHF\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, pneumonia, with intermittent respiratory\n distress\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:10 A.M. \n\n HISTORY: Critical aortic stenosis and pneumonia. Respiratory distress.\n\n IMPRESSION: AP chest compared to and and 2:\n\n Right perihilar edema present on has largely cleared. Interstitial\n edema has resolved, though pulmonary and mediastinal vascular engorgement\n persists and mild-to-moderate cardiomegaly is unchanged. Small bilateral\n pleural effusion is stable. There is no pneumothorax. Tip of the left PIC\n catheter projects over the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907771, "text": " 10:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval edema\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, pneumonia, with acute pulmonary edema\n yesterday\n REASON FOR THIS EXAMINATION:\n please eval edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Critical aortic stenosis, pneumonia.\n\n CHEST, AP: There are small bilateral pleural effusions, unchanged since the\n prior study from . There is unchanged appearance of left lower\n lobe consolidation. Mild pulmonary edema is present. Left-sided PICC line is\n seen with its tip at the cavoatrial junction.\n\n IMPRESSION: No interval change since with mild pulmonary edema,\n small bilateral effusions, and left lower lobe collapse.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906597, "text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, intubated with pneumonia.\n\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia.\n\n COMPARISON: .\n\n CHEST AP: There is stable cardiomegaly. The right mid zone lung pneumonia is\n improving. Small bilateral pleural effusions are present. The tip of the\n right IJ line is in the right atrium.\n\n IMPRESSION: Improving right mid zone pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 908655, "text": " 10:51 AM\n CHEST (PA & LAT) Clip # \n Reason: eval consol/ post op\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p AVR/CABG\n REASON FOR THIS EXAMINATION:\n eval consol/ post op\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old female status post AVR and CABG, referred for followup\n of pneumonia.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: There is a left-sided PICC line with tip in the distal\n SVC. There has been no change in cardiomegaly and the tortuous aorta. The\n patient is status post sternotomy and CABG with aortic valve prosthesis in\n stable position. There has been slight improvement in the right pleural\n effusion. The left pleural effusion persists, not significantly changed.\n There has been no change in a minimal amount of residual opacity at the site\n of the previously identified right upper lobe consolidation.\n\n IMPRESSION: Persistent small bilateral pleural effusions with slight interval\n improvement on the right. Minimal residual right upper lobe opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906738, "text": " 7:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval infiltrate and edema\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, pneumonia, requiring BiPAP\n REASON FOR THIS EXAMINATION:\n please eval infiltrate and edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old female with aortic stenosis, pneumonia, requiring\n BiPAP.\n\n COMPARISON: .\n\n FINDINGS: The tip of a right internal jugular catheter terminates at the\n cavoatrial junction. The cardiac and mediastinal contours are stable. There\n is continued perihilar consolidation and consolidation in the left\n retrocardiac region. No pneumothorax is identified. Small bilateral pleural\n effusions are present.\n\n IMPRESSION: Stable appearance of right upper lobe and perihilar and left\n basilar pneumonia. No evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906434, "text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval changes in pna\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, intubated with pneumonia.\n REASON FOR THIS EXAMINATION:\n ? interval changes in pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE FROM \n\n HISTORY: Critical aortic stenosis. Intubated with pneumonia.\n\n FINDINGS: An AP upright portable chest radiograph shows no significant\n radiographic change in the right upper lobe and perihilar consolidation and\n consolidation in the left retrocardiac region compared to yesterday's exam.\n The endotracheal tube remains in place, low in location, only approximately\n 1.5 cm above the carina. The carina appears splayed, suggesting enlargement\n of the left atrium but this is an unchanged finding. The patient's right-\n sided central venous catheter tip is at the level of the proximal right\n atrium. Nasogastric tube tip and side hole are both below the left\n hemidiaphragm. Small bilateral pleural effusions may be present.\n\n CONCLUSION:\n 1. Stable appearance of right upper lobe and perihilar and left basilar\n pneumonia compared to yesterday's exam. Note low location of endotracheal\n tube.\n\n" }, { "category": "Radiology", "chartdate": "2152-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 905396, "text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrates, ET tube placement\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, now intubated and febrile\n REASON FOR THIS EXAMINATION:\n Eval for infiltrates, ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Critical AS.\n\n PORTABLE AP CHEST.\n\n Compared to , the cardiomediastinal silhouette is normal and\n stable. Bilateral perihilar consolidations are new. There is no pleural\n effusion. There is no pneumothorax. The ET tube and NG tube are in good\n position.\n\n IMPRESSION: Depending upon clinical circumstances, bilateral perihilar\n consolidations could be due to pulmonary edema, hemorrhage or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2152-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 905924, "text": " 7:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate PA line placement and CHF\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, now intubated and febrile with PA line\n in place\n REASON FOR THIS EXAMINATION:\n Evaluate PA line placement and CHF\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: High temperature in an intubated patient.\n\n Portable AP chest x-ray was compared to the previous study from .\n\n The ET tube is in satisfactory position 2.5 cm above the carina. The\n Swan-Ganz catheter as well as NG tube in normal position. Heart size is\n enlarged unchanged in comparison to the previous study. The right upper lobe\n consolidation is seen obscuring the right hilus which is new in comparison to\n the previous film and most probably represents pneumonia. A small left\n pleural effusion unchanged to the previous film is again demonstrated.\n\n IMPRESSION:\n\n 1) New right upper lobe pneumonia.\n\n 2) Unchanged small pleural effusion on the left and satisfactory position of\n tubes and lines.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906092, "text": " 7:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for change, new infiltrate, failure\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, now intubated and febrile with PA line\n in place, with persistent fevers, ?pna\n REASON FOR THIS EXAMINATION:\n please evaluate for change, new infiltrate, failure\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST .\n\n COMPARISON: .\n\n INDICATION: Fever.\n\n Endotracheal tube, Swan-Ganz catheter and nasogastric tube are in satisfactory\n position. Heart size is mildly enlarged but stable. There is persistent\n asymmetrical consolidation in the right lung involving the periphery of the\n right upper lobe and the more central perihilar region. Within the left lung,\n there is a patchy opacity in the retrocardiac region. Previously reported\n congestive heart failure pattern shows interval improvement with decreasing\n perihilar haziness and improved vascular distinctness.\n\n Small right effusion is noted.\n\n IMPRESSION:\n 1. Persistent pneumonia right upper lobe and perihilar region.\n 2. Improving congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 906973, "text": " 4:06 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: DL 5F PICC inserted 53 cm to L basilic. Pls confirm placemen\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, pneumonia, now with breathing\n difficulty\n REASON FOR THIS EXAMINATION:\n DL 5F PICC inserted 53 cm to L basilic. Pls confirm placement for use.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old female with aortic stenosis, pneumonia and hypoxia.\n Evaluate PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: The tip of a left PICC terminates at the cavoatrial junction. The\n tip of a right jugular line projects over the upper SVC. Mild pulmonary edema\n has improved since , mild cardiomegaly is unchanged. Small to moderate\n bilateral pleural effusions are unchanged. There is gradual improvement in\n the right perihilar opacity. No pneumothorax is identified.\n\n IMPRESSION: Interval improvement in mild pulmonary edema; improving right\n perihilar pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-13 00:00:00.000", "description": "CT ABD&PELVIS W/O C COLON TECHNIQUE", "row_id": 907706, "text": " 3:16 PM\n CT ABD&PELVIS W/O C COLON TECHNIQUE Clip # \n Reason: Evaluate for GI source of bleeding.\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with hx anemia, preparing for Aortic valve replacement.\n REASON FOR THIS EXAMINATION:\n Evaluate for GI source of bleeding.\n CONTRAINDICATIONS for IV CONTRAST:\n renal insufficiency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR STUDY: Anemia. Evaluate for GI source of bleeding.\n\n No prior studies available for comparison purposes.\n\n TECHNIQUE: Axial contiguous slices obtained from the lung bases to the pubic\n symphysis following insufflation of intrarectal air to distend the entire\n colon. The study was performed in both the supine and decubitus positions.\n No intravenous contrast material was employed.\n\n CT COLONOGRAPHY: No suspicious polypoid lesions or areas of focal mural\n thickening are identified throughout the entire length of the colon, the colon\n was well distended down to apex of the cecum. Innumerable sigmoid diverticuli\n are present associated with mural thickening and lack of distention in both\n positions. A large amount of stool is present throughout the colon, but this\n displaces from supine to decubitus position. All fluid in the colon also\n displaces. No abnormal extrinsic mass compression was identified. There is\n no evidence for any colonic stricture or inflammatory change.\n\n CT ABDOMEN WITHOUT IV CONTRAST: Small bilateral pleural effusions are\n present, larger on left than the right side. Collapse of the left lower lobe\n is noted. The liver is unremarkable. The gallbladder has been removed.\n Spleen and adrenal glands and both kidneys are unremarkable. Numerous\n vascular calcifications are noted in the right kidney. Incidental note is\n made of an approximately 12 mm splenic artery aneurysm. A large anterior\n abdominal wall, small bowel containing hernia is noted. No free fluid or\n significant adenopathy is noted within the abdomen.\n\n PELVIS WITH CONTRAST: Multiple calcified uterine fibroids are identified.\n The uterus is enlarged. The bladder is collapsed around a Foley balloon. No\n free fluid or adnexal mass lesions are noted.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions identified in the bones.\n\n REFORMATTED IMAGES: Multiplanar reformatted images and full endoluminal\n navigation was performed in both the antegrade and retrograde direction which\n confirmed the presence of no suspicious polypoid lesions throughout the length\n of the colon but innumerable sigmoid diverticula.\n\n IMPRESSION:\n (Over)\n\n 3:16 PM\n CT ABD&PELVIS W/O C COLON TECHNIQUE Clip # \n Reason: Evaluate for GI source of bleeding.\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. No significant polypoid masses identified in the colon. The sensitivity\n of CT colonography for polyps greater than 1 cm is approximately 90%.\n Sensitivity for polyps 6-9 mm is approximately 60-70%. Flat lesions might be\n missed.\n\n 2. Please note that no IV contrast was used during the study due to patient's\n elevated creatinine level.\n\n 3. Incidental note made of 12 mm splenic artery aneurysm.\n\n 4. Multiple uterine fibroids.\n\n 5. Extensive sigmoid diverticulosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 908460, "text": " 9:37 AM\n CHEST (PA & LAT) Clip # \n Reason: eval post op\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman s/p AVR/CABG\n REASON FOR THIS EXAMINATION:\n eval post op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, AP AND LATERAL\n\n History of CABG and AVR.\n\n There is cardiomegaly and tortuosity of the thoracic aorta. There are\n bilateral pleural effusions and associated atelectasis at both lung bases.\n There has been partial resolution of the focal area of consolidation in the\n right upper lobe with minimal residual opacity in this location.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907119, "text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval progress of infiltrate, edema\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, pneumonia, with intermittent respiratory\n distress\n REASON FOR THIS EXAMINATION:\n please eval progress of infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST; 7:55 A.M., .\n\n HISTORY: Critical aortic stenosis, pneumonia, and intermittent respiratory\n distress.\n\n IMPRESSION: AP chest compared to and .\n\n The longstanding right upper lobe pneumonia has almost entirely cleared.\n Suggest continued followup until nodular residual has resolved. Small right\n pleural effusion has decreased. Small left pleural effusion and moderate\n cardiomegaly, as well as pulmonary vascular congestion are unchanged. No\n pneumothorax. Tip of a left PIC catheter projects over the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906858, "text": " 6:30 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? CHF\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, pneumonia, now with breathing\n difficulty\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with critical aortic stenosis and pneumonia\n with respiratory distress.\n\n Portable AP chest is compared with the prior from 11 hours earlier. The\n patient is slightly rotated. Again seen is a right internal jugular central\n venous catheter terminating at the cavoatrial junction. Given the difference\n in patient rotation, the cardiomediastinal silhouette is stable. There is\n interval worsening of bilateral lung base opacities and right upper lung zone\n opacities. There are bilateral pleural effusions. There is no pneumothorax.\n The surrounding osseous and soft tissue structures are stable. Clips are seen\n in the right upper quadrant.\n\n IMPRESSION: Interval worsening of bilateral airspace opacities which may\n represent worsening pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 908084, "text": " 7:24 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx effusion\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, pneumonia, with acute pulmonary edema\n yesterday s/p AVR and CABG\n REASON FOR THIS EXAMINATION:\n ptx effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post AVR and CABG yesterday, evaluate for effusion or\n pneumothorax.\n\n PORTABLE SUPINE RADIOGRAPH OF THE CHEST: An endotracheal tube is seen with\n the tip approximately 2.7 cm above the carina. A nasogastric tube is curled\n up in the esophagus with the tip projecting over the neck. A Swan-Ganz\n catheter is seen with the tip projecting over the main pulmonary artery. Two\n chest tubes are seen in the mediastinum. There are post-surgical changes of\n the mediastinum. There is an opacity at the left lung base which may represent\n atelectasis and/or pleural effusion. There likely is a small right-sided\n pleural effusion as well. The left retrocardiac opacity may represent left\n lower lobe atelectasis.\n\n IMPRESSION:\n\n 1. Nasogastric tube curled up in the esophagus and repositioning is\n necessary.\n\n 2. Satisfactory endotracheal tube and Swan-Ganz catheter position.\n\n 3. Opacities in the left lung base and in the retrocardiac region, most\n likely representing atelectasis and/or pleural effusion. Small right pleural\n effusion.\n\n Dr. has been paged to communicate these findings.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908139, "text": " 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct d/c, r/o ptx\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, pneumonia, with acute pulmonary edema\n yesterday s/p AVR and CABG\n REASON FOR THIS EXAMINATION:\n s/p ct d/c, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:52 AM, \n\n HISTORY: Critical aortic stenosis, pneumonia and pulmonary edema.\n\n IMPRESSION: AP chest compared to , 7 and 10:\n\n Small area of residual consolidation in the right upper lobe has been stable\n since . Left lower lobe atelectasis has worsened, small bilateral\n pleural effusions and moderate enlargement of the cardiac silhouette are\n stable. There is no pneumothorax. Tip of the left PIC catheter ends at the\n superior cavoatrial junction and a left supraclavicular Swan-Ganz line tip\n projects over the bifurcation of pulmonary artery.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906536, "text": " 4:43 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for fluid, other acute change\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, intubated with pneumonia, s/p extubation,\n now with SOB\n REASON FOR THIS EXAMINATION:\n evaluate for fluid, other acute change\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: Critical aortic stenosis, intubated with pneumonia, status post\n extubation, now with shortness of breath. Evaluate for fluid or other acute\n changes.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting upright position. Comparison is made with the next previous similar\n study obtained approximately 8 hours earlier during the same day. Cardiac\n enlargement persists, a configuration indicating left ventricular enlargement.\n Thoracic aorta diffusely widened and somewhat elongated. The pulmonary\n vasculature demonstrates congestive pattern with perivascular haze and minor\n amounts of pleural effusions blunting the lateral pleural sinuses.\n Parenchymal infiltrates are seen in the mid right and lower right lung field\n indicative of inflammatory infiltrates. These densities have progressed in\n comparison with the previous study, particularly in the right-sided lower lung\n field. The patient has been extubated during the interval. The right\n internal jugular venous approach central venous line remains in unchanged\n position terminating just above the expected entrance into the right atrium.\n No pneumothorax is present.\n\n IMPRESSION: Cardiac enlargement, pulmonary congestion, further increase of\n previously described right-sided pneumonic infiltrates.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907045, "text": " 8:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for change\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, pneumonia, now with breathing\n difficulty\n REASON FOR THIS EXAMINATION:\n evaluate for change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dyspnea. Aortic stenosis.\n\n A single upright portable chest radiograph demonstrates no change in the\n cardiomediastinal silhouette when compared to . The right internal\n jugular central venous catheter has been removed. The lung apices are\n excluded from the imaged field of view. Bilateral pleural effusions persist.\n Right mid lung and perihilar airspace opacity is improved in appearance when\n compared to multiple previous studies.\n\n IMPRESSION:\n\n Resolving right mid lung and perihilar pneumonia.\n\n Bilateral pleural effusions, unchanged.\n\n Limited study as the apices are excluded from the imaged field of view.\n\n" }, { "category": "Radiology", "chartdate": "2152-04-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906899, "text": " 9:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for change\n Admitting Diagnosis: PULMONARY EDEMA,AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with critical AS, pneumonia, now with breathing\n difficulty\n REASON FOR THIS EXAMINATION:\n evaluate for change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:40 A.M. .\n\n HISTORY: Critical aortic stenosis pneumonia and difficulty breathing.\n\n IMPRESSION: AP chest compared to and \n\n Mild pulmonary edema has improved since , mild cardiomegaly is stable,\n but mediastinal vascular engorgement has decreased. Small to moderate right\n pleural effusion is unchanged. Right perihilar pneumonia is stable. Tip of\n the right jugular line projects over the upper right atrium. No pneumothorax.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2142-06-15 00:00:00.000", "description": "Report", "row_id": 1326859, "text": "npn 2300-0700\n\nadmission note:62 y/o male c/o chest pain in .negative cardiac workup.ct abd showed 2cm duodenal mass. whipple w/ open cholecystectomy done.Long case,~10hr.EBL 1.5L,OR in 15L,OR out 4200.received kefzol 2 gm x 3 and flagyl x 2 in OR.received in tsicu intubated,on neosynephrine gtt,sedated on propofol.\n\npmh:see admission/fhp for pmh and home meds.\n\nneuro:arouses to voice,follows commands,mae's on 30mcg/kg/min of propofol.epidural w/ bupivicaine and dilaudid,initially at 8ml/hr, denied pain. reduced to 4ml/hr w/ no change in hemodynamics.turned off at 0600 as ordered by Dr..c/o pain when coughing.\n\ncv:very labile sbp.upon initial assessment,neo gtt at 1mcg/kg/min. titrated to max dose of 200mcg/min for map>60..changed to levophed, titrated to 0.25mcg/kg/min w/ map 58-60.given 3L fluid bolus of LR w/ transient effect.sr,70-90,no ectopy.cvp initially 6,rose to 11-13.lopressor held.pedal pulses weak.\n\nresp:see carevue for vent changes.currently on imv 40%,750x16,p 5/ps 5.ls clear,diminished bases.thick yellow sputum suctioned occasionally.sao2 100%.failed rsbi this am.\n\ngi:abd distended but soft on initial assessment.became firm and tender overnight, team informed.jp drain to bulb suction-115ml out of serosang drg.ngt to lws,bilious drg.-bs.R-sided transverse incision covered by dsd.\n\ngu:u/o <50ml/hr at times.increased w/ fluid boluses.urine clear, yellow.\n\nskin:intact.epidural and surgical sites wnl.\n\nid:tmax 101.9 orally.pan cultured this am.given tylenol supp this am.\n\nendo:bs 245 at 0400.covered per ss.\n\nheme:hct 42->35.7.\n\nsocial:wife and children in to visit.wife called overnight for update.\n\na/p:maintain sbp>90,or clarify parameters per sicu team.correct hypovolemia.provide adequate pain control.wean vent.\n" }, { "category": "Nursing/other", "chartdate": "2142-06-15 00:00:00.000", "description": "Report", "row_id": 1326860, "text": "Nursing Progress Note:\n\nPlease see CareVue for specifics.\n\nPt much improved today. Still receiving fluid boluses and weaning norepinephrine infusion. Extubated. Oriented. Pain free with intermittant dilaudid boluses.\n\nOn exam:\n\nResp:\nVentilation weaned throughout day and successfully extubated. Weaned to nasal prongs. Tolerating well. Voice slightly hoarse. Chest clear. Weak productive cough. Incentive spirometer in use with assistance.\n\nHemodynamically:\nSR, no ectopy, although rate increasing throughout afternoon. Metoprolol on hold until levophed weaned off per request TSICU team. Has received 1000mLs LR bolus since 0700hrs. CVP 10-12. Norepinephrine infusion remains on although rate weaned by half over day. Peripheries tepid to cool, with brisk capillary refill. Some peripheral edema. Some hemoserous oozing from central line insertion point (redressed). Diaphoretic this morning, less this afternoon. 12 lead ECGs attended. No chest pain.\n\nNeuro:\nEpidural catheter remains insitu (site satisfactory) but infusion off since nightshift. Pt's pain well controlled with intermittant dilaudid boluses (0.2-0.5mg). Weaned off propofol for extubation although was only lightly sedated with infusion. Now oriented x3 and in fair spirits. Cooperative with interventions. Occasionally restless.\n\nEndocrine:\nHyperglycemic. Commenced on insulin infusion.\n\nElectrolytes/ fluids:\nK remains within range of normal. Mg replaced. Maintenance changed to LR at 150mls/hr.\n\nGI:\nAbd distended (stable). Less firm this afternoon than this morning. Tender on light palpation of LLQ. Hypoactive bowel sounds. NGT draining well this evening.\n\nID:\nCultured this morning. Afebrile.\n\nRenal:\nGood urine output.\n\nSocial:\nFamily in to visit. Concerns addressed.\n\nPlan:\nWean pressor as able. Watch fluid status.\nTitrate insulin infusion. Consider subcutaneous sliding scale in preparation for transfer out.\nWatch abd distension.\nWatch respiratory status. Encourage deep breathing and coughing.\nContinued support for family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-06-16 00:00:00.000", "description": "Report", "row_id": 1326861, "text": "NPN 1900-0700\n\n Pt A&Ox3, little forgetful at start of shift, better in am. Calm and cooperative but pt had period of agitation/frustration in evening and was c/o pain, puritis and thirst. Repostioned several times in short period, given dilaudid and benadryl. Settled after awhile and slept most of night. Pt also with arthritic pain and hard to move arms above head.\n Lungs with few crackles in LLL and diminished in RLL. RR and sats WNL. Denies any SOB. C/o sore throat, explained it is due to ETT.\n Levo weaned to off and insulin gtt titrated to BS and now down to 2u/h. General edema, pale extremeties, palp pedal pulses.\n Abd soft, distended with +BS. Borderline concentrated UO.\n\n" }, { "category": "Radiology", "chartdate": "2142-06-19 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 831767, "text": " 1:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/o abscess, obstruction\n Admitting Diagnosis: DUODENAL MASS/SDA\n Field of view: 48 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p whipple with fevers and increased distention\n REASON FOR THIS EXAMINATION:\n r/o abscess, obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post Whipple with fevers and increased abdominal\n distention. Evaluate for abscess or obstruction.\n\n TECHNIQUE: CT of the abdomen and pelvis were performed after the\n administration of oral and IV contrast using the CT enterography technique.\n 150 cc of Optiray nonionic contrast was administered. Nonionic contrast was\n given for the patient's debility.\n\n COMPARISON: .\n\n FINDINGS:\n\n CT OF THE ABDOMEN W/CONTRAST: At the lung bases there are bibasilar changes\n of atelectasis, possibly associated with some degree of pneumonia. There is a\n small right-sided pleural effusion and a trace pleural effusion on the left.\n The liver has low attenuation after contrast administration, suggesting fatty\n infiltration of the liver. The spleen, adrenal glands, left kidney, and\n stomach appear unremarkable. In the upper pole of the right kidney, there is\n a 1.5 cm renal cyst. Post operative changes associated with the Whipple's\n procedure are seen. There is a small amount of fluid and air bubbles in the\n region of the gastrohepatic ligament, which are compatible with the recent\n surgical changes. A drainage catheter arising from the inferior edge of the\n left lobe of the liver extends inferior and posterior to the liver, and\n exiting the skin at the lateral mid right abdomen. There are no unexplained\n intra-abdominal fluid collections which have appearances suspicious for\n abscess.\n\n CT OF THE PELVIS W/CONTRAST: There are scattered diverticuli. The large\n bowel is otherwise unremarkable. There is air within the bladder, presumably\n associated with recent instrumentation with a Foley catheter. There is trace\n pelvic free fluid present.\n\n Examination of the osseous structures show no suspicious lytic or blastic\n lesions.\n\n Coronally and sagittally reformatted images of the abdomen were also obtained,\n which again show post operative changes relating to the Whipple's procedure,\n but no evidence of abscess or bowel obstruction.\n\n (Over)\n\n 1:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/o abscess, obstruction\n Admitting Diagnosis: DUODENAL MASS/SDA\n Field of view: 48 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1) Post operative fluid and air in the resection bed as well as mesenteric\n and omental fat stranding are consistent with recent surgery.\n 2) No evidence of focal abscess or bowel obstruction.\n 3) Fatty liver.\n 4) Bilateral lower lobe atelectasis, possibly related with some degree of\n consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2142-06-22 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 832114, "text": " 1:13 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PO and IV contrast: R/o abscess/collection, please consider\n Admitting Diagnosis: DUODENAL MASS/SDA\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p whipple with fevers and increased distention, with\n possible fluid collection and drainage from wound.\n REASON FOR THIS EXAMINATION:\n PO and IV contrast: R/o abscess/collection, please consider percutaneous\n drainage of collection, page (dr ) ()\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post Whipples procedure, with fevers and increased\n distention. Evaluate for abscess or fluid collection.\n\n TECHNIQUE: CT of the abdomen and pelvis were performed after the\n administration of oral and IV contrast, in comparison to the examination\n performed three days ago. 150 cc of Optiray nonionic contrast was used.\n Nonionic contrast was given due to patient debility.\n\n FINDINGS:\n\n CT of the abdomen with contrast: Bibasilar atelectasis is again seen, with a\n small right sided pleural effusion and a trace left effusion. Visualized\n portions of the heart and pericardium appear unremarkable.\n\n There is fatty change of the liver. Again, in the surgical and gallbladder\n bed, there is a small amount of free fluid containing air bubbles, with a\n drain running through this region. This has a very similar distribution as the\n examination performed three days ago. There has been no organization or\n loculation of this fluid. Pancreatic tail, spleen, and adrenal gland appear\n unremarkable. Tiny hypodensity within the interpolar region of the left\n kidney, as well as a right upper pole renal cysts are seen. There is no\n significant abdominal lymphadenopathy.\n\n CT of the pelvis with contrast: There is a Foley catheter within the bladder,\n and small amount of air is in the bladder. Large bowel and distal ureters\n appear unremarkable. There is no pelvic lymphadenopathy or free fluid.\n\n Examination of the osseous structures show no suspicious lytic or blastic\n lesions. Soft tissue edema is present.\n\n IMPRESSION: 1. Persistent and unchanged amount of fluid and air within the\n resection bed, mesenteric, and omental fat, which are consistent with the\n recent surgery. Drainage catheter runs through this fluid collection. 2. No\n loculated or organized fluid collections are seen. 3. Fatty liver. 4.\n Bilateral lower lobe atelectasis with small right sided pleural effusion.\n (Over)\n\n 1:13 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PO and IV contrast: R/o abscess/collection, please consider\n Admitting Diagnosis: DUODENAL MASS/SDA\n Field of view: 48 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2142-06-19 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 831714, "text": " 2:37 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: r/o dilated loop and free air.\n Admitting Diagnosis: DUODENAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with increasing distension and abodminal tenderness pod#4\n whipple\n REASON FOR THIS EXAMINATION:\n r/o dilated loop and free air.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Whipple procedure with abdominal distension and tenderness.\n\n There are a few mildly gas-distended loops of small bowel with gas present\n throughout the colon and in the rectum, findings consistent with postop ileus.\n The cecum is not unduly dilated. Catheter overlies right upper quadrant. No\n free intraperitoneal gas.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832758, "text": " 11:31 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: pt had a right sided picc line placed and needs tip confirma\n Admitting Diagnosis: DUODENAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p Whipple who needs picc for TPN.\n\n REASON FOR THIS EXAMINATION:\n pt had a right sided picc line placed and needs tip confirmation, please page\n at with wet read, thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right sided PICC line placement.\n\n COMPARISON: .\n\n CHEST, AP RADIOGRAPH: There is stable cardiac enlargement. The mediastinal and\n hilar contours are unremarkable. There is a right sided PICC line with tip in\n the distal SVC. Linear plate-like atelectasis is noted at the right lung base.\n The osseous structures are unremarkable.\n\n IMPRESSION: Right PICC line with tip in the distal SVC.\n\n" }, { "category": "Radiology", "chartdate": "2142-06-17 00:00:00.000", "description": "PL ABDOMEN (LAT DECUB ONLY) PORT LEFT", "row_id": 831588, "text": " 11:56 AM\n ABDOMEN (LAT DECUB ONLY) PORT LEFT Clip # \n Reason: R/o free air. PLEASE TAKE SECOND X-RAY WITH PATIENT ON SIDE\n Admitting Diagnosis: DUODENAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p Whipple with new fever to 102.8 and abdominal pain.\n REASON FOR THIS EXAMINATION:\n R/o free air. PLEASE TAKE SECOND X-RAY WITH PATIENT ON SIDE.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Whipple - febrile - abdominal pain.\n\n FINDINGS: Surgical skin staples are demonstrated and mesh material is noted\n as well. There is no evidence of abnormal distention of bowel loops nor\n evidence for free air.\n\n" }, { "category": "Radiology", "chartdate": "2142-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 831587, "text": " 11:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/o aspiration pneuomonia, nosocomial pneuomonia, atelectasi\n Admitting Diagnosis: DUODENAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p Whipple with new fever to 102.8 and decreased breath sounds.\n\n REASON FOR THIS EXAMINATION:\n R/o aspiration pneuomonia, nosocomial pneuomonia, atelectasis, and chf\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST @ 12:21:\n\n INDICATION: Fever.\n\n COMPARISON: .\n\n FINDINGS: ETT has been removed. The current study shows a markedly shallow\n inspiration. Right CVL remains with tip in SVC. Increased markings are seen at\n the bases and likely represent an element of CHF with some pleural fluid\n layering on the right. Poor visualization of left hemidiaphragm suggests\n either atelectasis or consolidation. Lateral views for when feasible.\n\n IMPRESSION:\n\n Shallow inspiration limits the assessment. There is an element of CHF and left\n lower lobe process cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2142-06-25 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 832376, "text": " 12:24 PM\n CT ABD W&W/O C; CT 150CC NONIONIC CONTRAST Clip # \n Reason: COLLECTION FLUID ? DRAINAGE\n Admitting Diagnosis: DUODENAL MASS/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p whipple with fevers and increased distention, with fluid\n collection please place drain under CT guidance\n REASON FOR THIS EXAMINATION:\n Drain placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Previous examination shows fluid collection. Status post Whipple\n resection.\n\n COMPARISON: Examination dated .\n\n TECHNIQUE: Axial multislice acquisition of the abdomen was performed without\n and with intravenous contrast.\n\n CONTRAST: 150 ml of Optiray was given because of the patient's poor general\n condition.\n\n CT OF ABDOMEN WITH INTRAVENOUS CONTRAST: The previously identified fluid\n collection has largely resolved, and there is extensive induration of the\n anterior abdominal wall. The fluid collection appears to have necessitated\n onto the anterior abdominal wall at the site of surgical scar. Status post\n Whipple's resection. Postoperative stranding is identified in the\n peripancreatic region, but no definite fluid collection or abscess is seen. No\n evidence of local lymphadenopathy. Both kidneys, adrenals, spleen and liver\n appear normal.\n\n There is evidence of bibasilar pleural effusions, associated with lung\n bibasilar atelectasis.\n\n The visualized bones appear normal.\n\n CONCLUSION:\n\n The previously demonstrated collection has necessitated onto the anterior\n abdominal wall. No significant fluid collection is now identified. No attempt\n at drainage was made.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2142-06-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 832766, "text": " 1:26 PM\n CHEST (PA & LAT) Clip # \n Reason: Pt needs repeat CXRY to confirm right PICC line placement un\n Admitting Diagnosis: DUODENAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with Chole and whipple who needs picc for tpn.\n REASON FOR THIS EXAMINATION:\n Pt needs repeat CXRY to confirm right PICC line placement unable to see PICC on\n last one, please page at with wet read, thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P PICC line placement for TPN\n\n COMPARISON: at 12:05\n\n PA AND LATERAL RADIOGRAPH: The cardiac, mediastinal and hilar contours are\n unremarkable. There is some minimal atelectasis at the right lung base. A\n right PICC line tip extends to the cavoatrial junction. The osseous\n structures are unremarkable. There are probable small bilateral pleural\n effusions.\n\n IMPRESSION:\n 1) PICC line tip extending to the cavoatrial junction.\n 2) Right lower lobe atelectasis and possible small bilateral pleural\n effusions.\n\n" }, { "category": "Radiology", "chartdate": "2142-06-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 831356, "text": " 8:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R IJ cvl\n Admitting Diagnosis: DUODENAL MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p Whipple\n REASON FOR THIS EXAMINATION:\n s/p R IJ cvl\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right IJ line placement.\n\n CHEST, AP: The tip of the endotracheal tube is about 6 cm above the carina.\n The tip of the right IJ line is in the distal SVC. A rounded, ring-like\n opacity is visualized in the right mid zone, possibly something lying outside\n of the chest. There is left lower lobe collapse/consolidation. The\n mediastinal and hilar contours are unremarkable. The lungs are clear. There\n are no pleural effusions.\n\n IMPRESSION: Right IJ line in the distal SVC. No pneumothorax. Rounded,\n ring-like opacity in the right mid zone, possibly something lying outside the\n chest. Follow up is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2142-06-14 00:00:00.000", "description": "O PORTABLE ABDOMEN IN O.R.", "row_id": 831354, "text": " 7:46 PM\n PORTABLE ABDOMEN IN O.R. Clip # \n Reason: S/P MISCOUNT OF SURGICAL EQUIPMENT, CHECK FOR FB\n Admitting Diagnosis: DUODENAL MASS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n History of erroneous instrument count.\n\n No surgical instruments or needles are detected.\n\n" }, { "category": "ECG", "chartdate": "2142-06-15 00:00:00.000", "description": "Report", "row_id": 273338, "text": "Sinus rhythm. Left atrial abnormality. Probable prior inferior myocardial\ninfarction. Compared to the previous tracing of no diagnostic change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2151-09-30 00:00:00.000", "description": "Report", "row_id": 1337037, "text": "NPN - admit\nNEURO: pt. admitted via guerney from ER, alert awake and oriented. MAE, follows commands. states he intermittantly has lack of sensation in feet. no complaint at this time.\n\nCV: stable sys bp 160, hr 80 sinus, peripheral pulses intact x 4 skin warm dry, pt afebrile. HCT 16 on arrival, no complaint of dizziness on standing.\n\nRESP: room air, breath sound clear.\n\nGU: vd qs amt. clear urine.\n\nGI: abd soft nontender. no stool since admit. NPO for procedure in am.\n\nACCESS: 2 PIV right and left arm. able to draw blood using PIV in right arm.\n\nSOCIAL: lives with SO . supportive but not here at time of admit. had been in ER with pt. today.\n\nPLAN: follow HCT transfuse goal 25. monitor mental/CIWA scale for hx of regular etoh use. IVF, I/O, NPO for now.\n" }, { "category": "Nursing/other", "chartdate": "2151-09-30 00:00:00.000", "description": "Report", "row_id": 1337038, "text": "NPN 0000-0730\nAssessment unchanged from prev. Three units PRC given . cont to monitor HCT. Pt. had no stools this am. CIWA 0-2 this am.\n\nPlan: cont workup this am. Eval. CIWA on cont. basis secondary to pt drinking 1 fifth gin a day. Activity as tol.\n" }, { "category": "Nursing/other", "chartdate": "2151-09-30 00:00:00.000", "description": "Report", "row_id": 1337039, "text": "see nursing transfer note for pmh and hospital course.\n" }, { "category": "Radiology", "chartdate": "2151-09-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 838676, "text": " 8:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with poor EF (around 35%) and bibasilar crackles.\n\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Poor ejection fraction and bibasilar crackles.\n\n COMPARISON: .\n\n TECHNIQUE: A single AP portable upright chest.\n\n FINDINGS: The heart size and mediastinal contours are within normal limits.\n There is prominence of the upper zone pulmonary vasculature and perihilar\n haziness consistent with pulmonary vascular congestion. No pleural effusion\n or pulmonary parenchymal consolidation is identified. No pneumothorax. The\n surrounding osseous structures appear unchanged.\n\n IMPRESSION: Mild pulmonary vascular congestion, improved since the time of\n the previous examination dated .\n\n\n" }, { "category": "ECG", "chartdate": "2151-10-01 00:00:00.000", "description": "Report", "row_id": 290549, "text": "Sinus rhythm\nLateral T wave changes may be nonspecific\nSince previous tracing of , lead reversal corrected\n\n" }, { "category": "ECG", "chartdate": "2151-09-30 00:00:00.000", "description": "Report", "row_id": 290550, "text": "Sinus rhythm\n*** arm lead reversal - only aVF, V1 - V6 analyzed ***\nLateral T wave changes are nonspecific\nSince previous tracing of , limb leads reversal seen\n\n" }, { "category": "ECG", "chartdate": "2151-09-29 00:00:00.000", "description": "Report", "row_id": 290551, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , no significant change\n\n" } ]

[ { "category": "Radiology", "chartdate": "2190-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 771284, "text": " 7:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 75 yr old male with altered mental status, ronchi and elevat\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with intracerebral bleed with question of aspiration pna\n REASON FOR THIS EXAMINATION:\n 75 yr old male with altered mental status, ronchi and elevated WBC r/o\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate for aspiration pneumonia, change in mental status, rhonchi\n and elevated white count.\n\n TECHNIQUE: Portable chest xray.\n\n There are no prior studies available for comparison.\n\n FINDINGS: The study is limited due to respiratory motion. The heart is normal\n in size. The aorta is unfolded and partially calcified. Multiple skin folds\n overlie the chest, there is no definite evidence of pneumothorax, large areas\n of consolidations or large effusions. There are degenerative changes in the\n spine.\n\n IMPRESSION: Limited study due to respiratory motion, no evidence of large\n areas of consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2190-09-18 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 771276, "text": " 4:31 PM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: R INTRVENTRICULAR AND INTRAPARENCYMAL HEMORRHAGE,LOOKING FOR SITE OF UNDERLYING VASCULAR LESION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with Mental retardation and Parkinsons disease with new Rt\n intraparenchymal and intraventricular hemorrhage\n REASON FOR THIS EXAMINATION:\n and CT angiogram r/o underlying vascular lesion as source of large Rt. sided\n intraventricular and intraparenchymal hemorrhage in this 75 yo with hx of\n mental retardation and Parkinsons disease\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT.\n\n CLINICAL INDICATION: 75 year old man with mental status changes. Found to\n have large intraparenchymal and intraventricular hemorrhage on CT scan from\n outside hospital. Evaluate for underlying vascular lesion.\n\n TECHNIQUE: Contiguous axial images were obtained from the foramen magnum\n through the cranial vertex prior to the administration of IV contrast.\n Thereafter, 100 cc of Optiray contrast was administered IV and a CTA of the\n circle of was performed.\n\n COMPARISONS: None.\n\n HEAD CT WITHOUT IV CONTRAST: As indicated from the patient's outside CT,\n there is a large focus of hemorrhage within the right frontoparietal region\n with hemorrhage extending into the posterior horns of both right and left\n lateral ventricles. There is effacement of the sulci on the right with edema\n surrounding this large area of hemorrhage. The hemorrhage measures\n approximately 6.6 x 4.3 cm in largest axial dimension. There may be just\n minimal midline shift to the left. The ventricles are enlarged bilaterally, a\n finding which is of uncertain chronicity in this elderly patient with history\n of dementia. There are hypodense regions within the periventricular white\n matter consistent with chronic microvascular infarcts.\n\n Following the administration of IV contrast, evaluation of the circle of\n was performed. No aneurysm is identified. No underlying enhancing\n lesions are seen within the largest area of hemorrhage. No vascular\n malformation is detected.\n\n There is fluid density within the bilateral maxillary sinuses, as well as\n several ethmoid air cells and the right frontal sinuses. No acute fractures\n are identified.\n\n IMPRESSION:\n\n 1) Large region of hemorrhage within the right frontoparietal region with\n extension into the posterior horns of both right and left lateral ventricles.\n Edema with mass effect on the adjacent sulci but with minimal, if any, midline\n (Over)\n\n 4:31 PM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: R INTRVENTRICULAR AND INTRAPARENCYMAL HEMORRHAGE,LOOKING FOR SITE OF UNDERLYING VASCULAR LESION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n shift.\n\n 2) No aneurysm detected on the IV contrast enhanced images. No enhancing\n lesion detected within the region of hemorrhage and no AV malformation seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-09-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 771317, "text": " 11:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CONFIRM NG TUBE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n CONFIRM NG TUBE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n CHEST, AP: Comparison is made to prior film . There is interval\n placement of an NG tube, with tip overlying fundus. The heart is not\n enlarged. There is interval development of ill-defined opacity in the right\n lower lobe, consistent with a focal consolidation vs. aspiration. Probable\n small right effusion. Assymetric right apical pleural thickening. The left\n lung is grossly clear. Thin linear density overlying left lung medially is\n thought to represent artifact.\n\n IMPRESSION:\n\n 1. Tip of NG tube over fundus.\n 2. New consolidation at right base - ?right lower lobe pneumonia.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2190-09-19 00:00:00.000", "description": "Report", "row_id": 1539231, "text": "Micu Nursing Progress Notes:\n\nPatient admittted from ER where he had been sent from Hospital. He had been noted to have new onset of left hemiplegia by his niece, who is also his health care proxy. CT scan showed right\nintercerebral hemorrhage. He is a DNR/DNI per his niece, and no surgical interventions will be done. He will be managed aggressively per niece's request. He arrived in the unit ~21:30 on Nipride gtt, which has been titrated to keep his SBP 140-150. Currently he is on 1.1mcg/kg/min. He is receiving NS at 60cc/hr. He has a history of mental retardation, Parkinson's, and an GI bleed from 20 years ago.\nHe reportedly functions at baseline at the level of a 7 year old. His baseline status was that he talked and walked independently. He is having intermittent tremors of his right side. Team is aware and feels they are Parkinsonian in nature as he did not take his Sinemet today, vs seizure. Pupils are ~4mm, right pupil is sluggish, left is briskly reactive. Corneal reflexes, gag and cough are impaired. He does open his eyes to verbal stimulation and did attempt to squeeze caretakers hand when requested to do so. He makes purposeful movements with his right hand to remove face mask and pull at Foley. An A-line was placed in his left radial shortly after arrival. Pulmonary status: Lung sounds are diminished, rhonchorous, with exception of left base, which is clear. He arrived on NC at 4L which had to be increased to 6L secondary to sats in 80s. A face tent was place, with NC, but this was replaced with a NRB after a drop in sats to 70s to 80s. Currently he is mid 90s. Lines: A right peripheral 20g was placed at Hospital, and a left peripheral 18 g placed on arrival in ER.\nSkin: Intact; patient was bathed, turned s-s. GI/GU: NPO; urine output minimal. No stool. Labs: pending.\nPlan: Monitor neuro symptoms, resp. status. Comfort measures.\n RN\n" }, { "category": "Nursing/other", "chartdate": "2190-09-19 00:00:00.000", "description": "Report", "row_id": 1539232, "text": "NPN-MICU\nMr (call him \"\") has made little improvement today.\nNeuro:he cont to rsp to name (sometimes it is just an eyebrow mvmt) and other times he has opened eyes but not spont. He is moving only his rt arm and occas will lift rt leg. He is not speaking and only looked at family members when they arrived. He cont with the parkinsonian tremors. He does have a cough and gag when stimulated.\nCV:pt weaned off nipride with hydralizine and po lopressor. So far he has done well. He can have prn NTP if BP >170. He has had several episodes of ST/SVT to rate of 120 but breaks on own.\nResp: pt was doing well until about 12 when he had a RR of 40-50 with drop in sat to 74%. He was sx and changed back to 100% NRB. He has since recovered his sat to 95%( but that is right after sx) and is currently maintaing sats btw 90-93% but with a RR of 30-40. He prob has ASP PNX so due to his status, we will be aggressive with CPT and sx as needed, (pt is DNR/DNI), no IVAB.\nGI:NGT placed and TF started now at 20cc/hr, sm amt of residuals, no stool.\nGU: u/o cont to be marginal despite a nother IVB but now up to 25cc/hr. He cont on IVF.\nID:he temp is increasing slowly and WBC up to 25. He has cx pnd but we will hold on furhter tx for now.\nStatus:Both Neuro Med and Neurosurgery had talked to pt's 2 neices regarding his care and outcome. They have reaffirmed his DNR/DNI status and that they do not want him in any pain. We will cont current care with BP controll and monitoring neuro satus but not implement any further therapy. They may initiate CMO tomorrow if he does not show any further improvement and looks uncomfortable.\nA/P:Will closely follow for changes and call SICU team if pt looks uncomfortable.\n Follow pt's rsp to CV meds and use NTP if BP >170.\n Aggressive pulm toilet\n Adjust TF to tol Goal of 60cc/hr.\n\n" }, { "category": "ECG", "chartdate": "2190-09-18 00:00:00.000", "description": "Report", "row_id": 171054, "text": "Sinus rhythm. Right bundle-branch block. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2188-05-03 00:00:00.000", "description": "Report", "row_id": 77732, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 66\nWeight (lb): 200\nBSA (m2): 2.00 m2\nBP (mm Hg): 132/48\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 15:43\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\n1. The left atrium is mildly dilated. The right atrium is moderately dilated.\n2. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n3. The aortic valve leaflets are mildly thickened. No aortic regurgitation is\nseen.\n4. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n5. Compared with the report of the prior study (images unavailable for review)\nof , there is no significant change\n\n\n" }, { "category": "ECG", "chartdate": "2188-04-16 00:00:00.000", "description": "Report", "row_id": 189461, "text": "Sinus tachycardia. Delayed precordial R wave progression. Compared to the\nprevious tracing of no diagnostic interim change.\n\n" }, { "category": "Radiology", "chartdate": "2188-05-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909953, "text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? effusion ? chf\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p VATS.\n\n REASON FOR THIS EXAMINATION:\n ? effusion ? chf\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Status post VATS procedure.\n\n Feeding tube coils in the proximal stomach with distal tip directed cephalad.\n Right internal jugular catheter remains in standard position. Cardiomegaly\n and bilateral perihilar alveolar edema are without interval change allowing\n for technical differences. Moderate right and small left pleural effusions\n are also stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-05 00:00:00.000", "description": "LP UNILAT UP EXT VEINS US LEFT PORT", "row_id": 910196, "text": " 8:27 AM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: LEFT ARM SWELLING\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p Right VATS secondary to RML nodule now dx as cancer\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND STUDY OF LEFT UPPER LIMB VEINS.\n\n CLINICAL DETAILS: Evaluate for deep venous thrombosis.\n\n FINDINGS:\n\n The left upper limb veins appear patent and increased venous return with\n augmentation on Doppler demonstrated. Left internal jugular, left subclavian,\n left axillary and left brachial vessels demonstrated to be patent.\n\n CONCLUSION:\n\n No left upper limb deep venous thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909451, "text": " 9:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval effusions\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p extubation\n REASON FOR THIS EXAMINATION:\n eval effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:30 A.M., \n\n HISTORY: Extubation. Lung nodules. Status post VATS.\n\n IMPRESSION: AP chest compared to chest films since to most recently\n , 5:21 a.m.:\n\n Left perihilar consolidation has improved and mild-to-moderate generalized\n pulmonary edema is less severe, following extubation. Heart is moderately\n enlarged. Small right pleural effusion has increased. No pneumothorax. Tip\n of the right jugular line projects over the superior cavoatrial junction. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 909180, "text": " 10:33 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p RIJ central line. Please assess for line placement, plea\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p right IJ central line placement\n REASON FOR THIS EXAMINATION:\n s/p RIJ central line. Please assess for line placement, please r/o pneumo\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW, PORTABLE\n\n INDICATION: 67-year-old female patient with line placement.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study of yesterday.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. The\n right jugular IV catheter terminates in the right atrium. The left subclavian\n IV catheter terminates in the SVC. A feeding tube terminates in the gastric\n body. No pneumothorax is identified.\n\n There are increased opacities in both lower lobes indicating pneumonia versus\n aspiration. The heart is not enlarged. There is probably very mild pulmonary\n edema. No pneumothorax is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909107, "text": " 2:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Is dobhoff tube in stomach?\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with history of CVA and breast cancer now with\n multiple new lung nodules.s/pRVATS middle lob wedge resection. Intubated\n for ^^ secretions//S/p BAL - Please note that patient has\n significant left sided weakness.\n\n REASON FOR THIS EXAMINATION:\n Is dobhoff tube in stomach?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post-right VATS with middle lobe wedge resection.\n\n CHEST AP: Since the prior study from one day earlier, there has been interval\n worsening of the right lower lobe consolidation. The left mid and lower lung\n consolidations are stable. The previously seen vascular congestion has\n resolved. The tip of the endotracheal tube is about 3 cm above the carina.\n The tip of the Dobhoff tube is in the stomach. Surgical clips are present\n overlying the left costophrenic angle.\n\n IMPRESSION: Multifocal consolidation likely representing pneumonia with\n interval worsening in the right lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909655, "text": " 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? effusions ? chf\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p VATS. . .assess effusions/chf\n\n REASON FOR THIS EXAMINATION:\n ? effusions ? chf\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Status post VATS procedure, evaluation for congestive\n heart failure or infiltrate.\n\n Portable supine AP radiograph was compared to the previous film from .\n\n The Dobbhoff tube is inserted and lies within the stomach. The right internal\n jugular line is inserted with its tip projecting over the distal vena cava.\n\n The heart size is hard to evaluate because of bilateral pulmonary\n consolidations, more pronounced in the lower lobes and representing severe\n pulmonary edema, slightly worsened in comparison to the previous film. The\n right pleural effusion is unchanged.\n\n IMPRESSION:\n 1. Severe pulmonary edema, slightly worsened in comparison to the previous\n film.\n\n 2. Right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910071, "text": " 5:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: F/u CHF.\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p VATS.\n\n REASON FOR THIS EXAMINATION:\n F/u CHF.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY, \n\n COMPARISON: .\n\n INDICATION: CHF.\n\n A feeding tube remains in place with tip directed cephalad in the stomach.\n The heart is enlarged. There has been interval improvement in degree of\n pulmonary edema. Bilateral pleural effusions, right greater than left are\n unchanged as well as an area of post-operative atelectasis adjacent to\n surgical chain sutures in the periphery of the right lower lobe.\n\n IMPRESSION: Improving congestive heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910594, "text": " 7:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for atelectasis and pneumo hemo thorax\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p VATS.\n\n REASON FOR THIS EXAMINATION:\n Eval for atelectasis and pneumo hemo thorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old female, status post VATS.\n\n COMPARISON: .\n\n AP SEMI-ERECT CHEST: There has been interval removal of a Dobbhoff feeding\n catheter. No pneumothorax is identified. A small-to-moderate right pleural\n effusion and bilateral perihilar alveolar edema are without interval change\n allowing for technical differences. Moderate cardiomegaly and widened\n appearance of the mediastinum are stable. Degenerative changes are seen\n within the thoracic spine.\n\n IMPRESSION:\n 1. No evidence of pneumothorax.\n 2. Unchanged small-to-moderate right pleural effusion.\n 3. Stable diffuse infiltrative pulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908193, "text": " 9:20 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Assess for pneumothorax, widened mediastinum, etc\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p R VATS wedge x3 RML\n\n REASON FOR THIS EXAMINATION:\n Assess for pneumothorax, widened mediastinum, etc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old female status post right VATS wedge with x-ray of\n wide mediastinum. Assess for pneumothorax, widening of mediastinum, etc.\n\n COMPARISON: portable upright chest radiograph.\n\n FINDINGS: There has been interval increase in bilateral opacities within the\n lungs consistent with worsening pulmonary edema. The cardiac, mediastinal and\n hilar contours are difficult to discern, however, appear similar in size with\n more ill-defined margins. This finding can be caused by pulmonary edema.\n Difficult to rule out underlying mediastinal pathology. Right middle lobe\n opacity likely representing site of wedge resection.\n\n IMPRESSION:\n Diffuse hazy opacities bilaterally consistent with worsening pulmonary edema.\n Mediastinal and cardiac contours grossly appear similar in size compared to\n prior study, however, more ill-defined borders are present which likely\n represents overlying pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 908350, "text": " 9:43 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: new line\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p R VATS now w/ worsening pulm status\n\n REASON FOR THIS EXAMINATION:\n new line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE LINE PLACEMENT CHEST RADIOGRAPH\n\n HISTORY: Worsening pulmonary status, status post right VATS.\n\n Portable supine chest radiograph shows interval placement of nasogastric tube\n and left subclavian central venous catheter compared to a study from four\n hours earlier. These appear in satisfactory position and no pneumothorax is\n seen. Also in the interim, the patient has been endotracheally intubated but\n the tip of the tube is low, less than 1.5 cm above the carina. All the lobes,\n however, remain aerated. Sutures are seen at the right lung base and there\n remains obscuration in the left retrocardiac region possibly related to\n atelectasis. Some slight peribronchial cuffing is noted in the perihilar\n regions bilaterally without obvious vascular congestion or edema.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908664, "text": " 12:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please assess for pneumo, effusion, worsening failure, etc\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with history of CVA and breast cancer now with multiple\n new lung nodules.s/pRVATS middle lob wedge resection. Intubated for ^^\n secretions//S/p BAL - Please note that patient has significant left\n sided weakness.\n REASON FOR THIS EXAMINATION:\n Please assess for pneumo, effusion, worsening failure, etc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right VATS, middle lobe wedge resection for lung\n nodules.\n\n COMPARISON: Eight hours earlier.\n\n CHEST AP: There is no interval change with the prior study. The tip of the\n endotracheal tube, left subclavian line, and NG tubes are in unchanged\n position. Bilateral consolidations are again noted, left greater than right\n with residual opacity visualized at the site of the right middle lobe\n resection.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 908402, "text": " 3:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Stroke.\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with decreased mental status s/p VATS.\n REASON FOR THIS EXAMINATION:\n Stroke.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST DATED \n\n HISTORY:\n\n TECHNIQUE: Contiguous 5-mm axial tomographic sections were obtained from the\n skull base to the vertex and viewed in brain and bone window on the\n workstation.\n\n FINDINGS: Comparison to a head CT of . There is an old right occipital\n infarct. There is associated volume loss with ex vacuo dilatation of the\n occipital and temporal horns and atrium of the right lateral ventricle. There\n is also similar low- attenuation involving the right splenium of the corpus\n callosum, as well as the posterior portion of the ipsilateral thalamus. These\n findings reflect remote infarction in the right PCA territory. There is also\n moderate low- attenuation in bihemispheric periventricular white matter, as\n well as the brain stem, representing chronic micro-ischemic change. There is\n a more vague low-attenuation region involving the right corona radiata and\n basal ganglia, also likely ischemic, but of indeterminate age. There is no\n evidence of hemorrhage. Incidentally noted is an 8-mm calcification at the\n periphery of the left parietovertex. This may represent a small calcified\n meningioma.\n\n The patient is intubated, with only a small amount of mucosal thickening\n involving the ethmoid sinuses. Also noted is dense materail in the left\n globe, unchanged.\n\n IMPRESSION:\n 1. No definite acute intracranial abnormality. MRI with diffusion- weighted\n sequence may be worthwhile.\n 2. Old right PCA territorial infarct.\n 3. Moderate chronic micro-ischemic change in periventricular white matter\n with scattered chronic lacunes.\n\n COMMENT: These findings were transmitted electronically to the emergency\n department.\n\n (Over)\n\n 3:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Stroke.\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2188-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908625, "text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval infil\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with history of CVA and breast cancer now with multiple\n new lung nodules.s/pRVATS middle lob wedge resection. Intubated for ^^\n secretions//S/p BAL - Please note that patient has significant left sided\n weakness.\n REASON FOR THIS EXAMINATION:\n eval infil\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post VATS.\n\n COMPARISON: .\n\n Tip of the endotracheal tube is 3.4 cm above the carina. Tip of the NG tube\n projects beyond the edge of the film in the stomach. Tip of the left\n subclavian line is at the junction of the innominate vein and SVC. There are\n bilateral perihilar infiltrates as well as a left lower lobe infiltrate.\n These are stable since the prior study.\n\n IMPRESSION: Stable infiltrates. Tubes and lines in good position.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908573, "text": " 4:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u s/p VATS\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with history of CVA and breast cancer now with multiple\n new lung nodules.s/pRVATS middle lob wedge resection. Intubated for ^^\n secretions//S/p BAL - Please note that patient has significant left sided\n weakness.\n REASON FOR THIS EXAMINATION:\n f/u s/p VATS\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW\n\n HISTORY: CVA and breast cancer with new lung nodules.\n\n REFERENCE EXAM: .\n\n The ET tube tip is approximately 3 cm above the carina. The NG tube tip is\n poorly visualized, it is at least below the diaphragm. There is dense\n opacification in the perihilar regions in bilateral lower lobes that has\n increased slightly compared to the film from the prior day. There is no\n pneumothorax. There is a small right effusion.\n\n IMPRESSION: Increased bilateral infiltrates.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908842, "text": " 10:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for fluid overload, interval change, etc\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with history of CVA and breast cancer now with\n multiple new lung nodules.s/pRVATS middle lob wedge resection. Intubated\n for ^^ secretions//S/p BAL - Please note that patient has\n significant left sided weakness.\n\n REASON FOR THIS EXAMINATION:\n assess for fluid overload, interval change, etc\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:53 A.M., \n\n HISTORY: CVA and breast cancer. New lung nodules.\n\n IMPRESSION: AP chest compared to through 18.\n\n Although pulmonary edema has cleared from the right upper lung, it remains\n substantial in the left lung. Right lower lobe atelectasis and\n small-to-moderate right subpulmonic pleural effusion is stable. Cardiac\n silhouette is partially obscured by edema on the left and atelectasis on the\n right. Mediastinal widening suggests vascular engorgement and elevated\n central venous pressure. ET tube and left subclavian line in standard\n placement. Nasogastric tube passes through the mid stomach and out of view.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908198, "text": " 1:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for pneumo, effusion, etc\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p R VATS wedge x3 RML\n\n REASON FOR THIS EXAMINATION:\n Please assess for pneumo, effusion, etc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right VATS. Evaluate for pneumothorax or effusion.\n\n CHEST AP: Since the study from there has been improving heart\n failure. There is a probable right effusion. Volume loss is seen in the\n right lung. The previously seen right lower lobe opacity likely secondary to\n hemorrhage is resolved. There is discoid atelectasis at the left lung base.\n\n IMPRESSION: Interval resolution of the right lower lobe postoperative\n hematoma/seroma. No pneumothorax. Probable small right effusion.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908320, "text": "\n CHEST (PORTABLE AP) Clip # \n Reason: eval infil\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p R VATS now w/ worsening pulm status\n\n REASON FOR THIS EXAMINATION:\n eval infil\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Status post right VATS with worsening of pulmonary\n status.\n\n AP upright portable chest radiograph was compared to the previous film from\n .\n\n Compared to the previous study, there has been interval worsening of the left\n lower lobe consolidation with no significant change in the right basilar\n opacity. The right basal opacity appearance suggests atelectasis of the lower\n lung atelectasis. Small bilateral pleural effusion is unchanged. No evidence\n of congestive heart failure is present.\n\n IMPRESSION:\n\n 1) Worsening of the left lower lobe consolidation.\n\n 2) The right lower lung appearance suggest atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 908742, "text": " 11:00 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p line placement\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with history of CVA and breast cancer now with multiple\n new lung nodules.s/pRVATS middle lob wedge resection. Intubated for\n ^^ secretions//S/p BAL - Please note that patient has significant\n left sided weakness.\n REASON FOR THIS EXAMINATION:\n s/p line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old female with breast cancer, status post right middle lobe\n VATS.\n\n COMPARISON: .\n\n AP SUPINE PORTABLE CHEST: Endotracheal tube tip is at the level of the\n clavicular heads. Left subclavian central line is at the junction of the\n brachiocephalic and SVC. Nasogastric tube terminates in the stomach. There\n has been no significant interval change in bilateral lower lobe\n consolidations, left greater than right, and residual opacity at the right\n middle lobe resection site. Heart size and mediastinal contours are not\n changed.\n\n IMPRESSION: No significant change in bilateral lower lobe consolidations and\n residual opacity at the right middle lobe resection site.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908399, "text": " 3:53 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: F/u s/p bronch.\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p R VATS now w/ worsening pulm status.\n\n REASON FOR THIS EXAMINATION:\n F/u s/p bronch.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post right-sided VATS, now worsening pulmonary status.\n Follow up status post bronchoscopy.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n semi-upright position and comparison is made with a similar previous\n examination obtained six hours earlier during the same day. The patient\n remains intubated, the ETT terminating in the trachea some 3 cm above the\n level of the carina. NG tube reaches far below the diaphragm. Left\n subclavian approach central venous line in unchanged position. No\n pneumothorax has developed. There is now a more extensive diffuse density in\n the right lower lobe area presumably the area where bronchoscopic intervention\n was performed during the interval. No other new pulmonary abnormalities are\n identified.\n\n IMPRESSION: No pneumothorax. New right basal density probably related to\n intervention.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910334, "text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate lung field\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p VATS.\n\n REASON FOR THIS EXAMINATION:\n evaluate lung field\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old status post VATS.\n\n COMPARISON: .\n\n AP SUPINE CHEST RADIOGRAPH:\n\n Feeding tube tip is within the stomach and unchanged. There has been interval\n removal of right IJ catheter. Heart, mediastinal and hilar contours are\n unchanged. Small-to-moderate right pleural effusion and diffuse infiltrative\n pulmonary process is unchanged. As mentioned previously, longstanding nature\n of abnormality is more consistent with heart failure and pulmonary edema.\n\n IMPRESSION: Stable diffuse infiltrative pulmonary process consistent with\n pulmonary edema. Small-to-moderate right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-25 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 909080, "text": " 10:40 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate for priamry pulmonic process leading to failure to\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n Evaluate for priamry pulmonic process leading to failure to extubate s/p RML\n lobectomy\n CONTRAINDICATIONS for IV CONTRAST:\n Poor renal function\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory failure in patient after right middle\n lobe lobectomy.\n\n COMPARISONS: Chest CT from and chest x-ray from , and\n .\n\n TECHNIQUE: MDCT of the chest without injecting of IV contrast was obtained\n with 1.25 and 5 mm. The axial images reviewed.\n\n The patient is status post right middle lobe lobectomy. The ET tube is\n inserted with its tip ending 1 cm above the carina. The NG tube is inserted\n running into the stomach. The central venous line tip is in the left\n brachiocephalic trunk.\n\n The heart is markedly enlarged. Coronary and aortic valve calcifications are\n noted. New pericardial effusion is present. Multiple mediastinal nodes\n measuring up to 1 cm in the shortest diameter are seen predominantly in the\n prevascular, supracarinal, and subcarinal locations. These nodules are\n slightly enlarged in comparison to the previous CT.\n\n The pulmonary windows demonstrate large bilateral basal consolidations with\n air bronchogram within it. In addition there is mixed ground-glass and true\n consolidation in left upper lobe. The lower lung also demonstrates some areas\n of ground-glass opacity with interlobular wall thickening. No sizable amount\n of pleural effusion is seen.\n\n The upper images of the abdomen demonstrate gallstones with no evidence of\n cholecystitis. Prominent aortic and splenic artery calcifications are noted.\n\n The bone window images do not reveal any lytic or blastic pathology suspicious\n for malignancy.\n\n Post-surgical changes and breast tissue mass is seen within the left breast,\n unchanged in comparison to the previous study.\n\n IMPRESSION:\n\n 1. Above-described pulmonary findings suggest the possibility of bilateral\n ARDS. Partial resolution of pneumonia is also seen in the left upper lung as\n (Over)\n\n 10:40 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate for priamry pulmonic process leading to failure to\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n well as mild congestive heart failure predominantly in the lower lobes.\n\n 2. Multiple mediastinal nodules slightly enlarged which may be reactive.\n\n 3. Low position of the trachea. These findings were discussed with Dr. \n during the dictation of this study.\n\n 4. Stable post-surgical changes in the left breast.\n\n" }, { "category": "Radiology", "chartdate": "2188-05-06 00:00:00.000", "description": "CT UP EXT W/O C", "row_id": 910417, "text": " 2:38 PM\n CT UP EXT W/O C Clip # \n Reason: Left arm evaluation after fall.\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with\n REASON FOR THIS EXAMINATION:\n Left arm evaluation after fall.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: CT left shoulder.\n\n HISTORY: Status post fall.\n\n CT LEFT SHOULDER\n\n TECHNIQUE: Axial images were obtained through the left shoulder. Subsequently\n limited sagittal and coronal reformatted images were acquired.\n\n FINDINGS: There is no evidence of proximal humeral fracture. The glenoid and\n acromioclavicular joints are intact. Mild osteoarthritic changes are seen at\n the acromioclavicular joint. The coracohumeral distance is slightly narrowed.\n Note is made of calcific density at the attachment site of the pectoralis\n major tendon on to humeral shaft.\n\n The visualized portions of the lungs show parenchymal opacities, suggesting\n atelectasis/pulmonary edema.\n\n IMPRESSION: No evidence of left shoulder and proximal humeral shaft fracture.\n\n There are surgical clips in the left breast with small amount of fluid which\n may represent seroma from recent biopsy, would recommend clinical correlation.\n If there is no history of recent biopsy, mammography is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2188-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909848, "text": " 10:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p VATS.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old post VATS and CHF.\n\n PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH. Comparison is made to supine\n radiograph performed one day earlier.\n\n Marked congestive heart failure appears slightly worse with more coalescent\n interstitial and alveolar opacity in the left mid lung zone. The right IJ\n central venous catheter is stable in position. The Dobhoff feeding tube is\n coiled in the stomach.\n\n IMPRESSION:\n Possible minimal worsening of severe CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909302, "text": " 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: surveillance\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p right IJ central line placement\n\n REASON FOR THIS EXAMINATION:\n surveillance\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:21 A.M. \n\n HISTORY: Right IJ line placement.\n\n IMPRESSION: AP chest compared to , and 23:\n\n Heterogeneous consolidation in both lungs has worsened since probably\n representing superimposition of edema, since there is more mediastinal\n vascular dilatation in the setting of severe cardiomegaly. Underlying\n pneumonia or pulmonary hemorrhage may well be present. At least a small\n volume of pleural fluid is present bilaterally. ET tube is in standard\n placement, feeding tube passes into the stomach and out of view. The tip of a\n right internal jugular line projects over the superior cavoatrial junction or\n upper right atrium, unchanged in position since . No pneumothorax\n present.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909237, "text": " 3:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change.\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p RML VATS/wedge with post-op respiratory failure, poss ARDS.\n REASON FOR THIS EXAMINATION:\n assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE\n\n INDICATION: 57-year-old female patient with VATS wedge of the right middle\n lobe.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study of yesterday.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. A\n feeding tube courses towards the stomach. The right jugular IV catheter\n remains in place. The left subclavian IV catheter has been removed. No\n pneumothorax is identified.\n\n There is continued pulmonary edema due to ARDS, which is superimposed by the\n pneumonia in both lower lobes.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-06 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 910414, "text": " 2:12 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: S/P FALL OUT OF CHAIR\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old woman status post fall out of chair.\n\n SINUS CT WITHOUT CONTRAST:\n\n TECHNIQUE: Axial non-contrast images, with coronal reformatted images.\n No comparison.\n\n FINDINGS: There is no evidence of facial fracture. Orbital walls are intact.\n There is minimal mucosal thickening in left sphenoid sinus air cell and right\n maxillary sinus. Bilateral mastoid air cells are opacified with fluid,\n mucosal thickening, or a combination of the two.. No evidence of soft tissue\n swelling is noted.\n\n IMPRESSION:\n 1. No evidence of facial bone fracture. Mucosal thickening in left sphenoid\n air cell and right maxillary sinus, likely inflammatory in origin. For more\n detailed evaluation of the brain, please also refer to the official report of\n CT head performed on the same day.\n 2. Opacification of bilateral mastoid air cells, likely inflammatory in\n origin.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-06 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 910410, "text": " 1:56 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Please evaluate for evidence trauma\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p fall out of chair\n REASON FOR THIS EXAMINATION:\n Please evaluate for evidence trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old female, status post fall out of chair; evaluate for\n evidence of trauma.\n\n TECHNIQUE: Helical 2.5 mm axial tomographic sections were obtained from the\n skull base through the mid-T1 level, sagittal and coronal reformations were\n prepared and the images are viewed in bone and soft tissue window on the\n workstation.\n\n FINDINGS: There is a nasogastric tube in situ, which may limit the evaluation\n of the prevertebral soft tissues but there is no gross swelling or hematoma.\n There is straightening of the normal cervical lordosis, but the alignment is\n otherwise preserved and no acute fracture is seen. The atlanto-occipital and\n atlantoaxial relationships are maintained. There are multilevel degenerative\n changes, most marked at the C4-5 and C5-6 levels, with mild-moderate disc-\n osteophyte complexes; however, these do not significantly narrow the spinal\n canal. There is no epidural hematoma and the outline of the thecal sac is\n grossly unremarkable.\n\n Incidentally noted is fluid/debris in numerous mastoid air cells, bilaterally.\n Also noted is an inhomogeneous appearance to the ventral aspect of both lobes\n of the thyroid gland with relatively well-defined low-attenuation\n foci, immediately subjacent to the strap muscles, which may represent cystic\n change.\n\n IMPRESSION:\n 1. No evidence of acute injury.\n 2. Degenerative changes, most marked at the C4-5 and C5-6 levels.\n 3. Possible cystic or other abnormality involving the ventral aspect of the\n thyroid gland; if warranted, this could be further assessed by focused\n son.\n\n" }, { "category": "Radiology", "chartdate": "2188-05-06 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 910411, "text": " 1:57 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: please evaluate for evidence trauma\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p fall out of chair\n REASON FOR THIS EXAMINATION:\n please evaluate for evidence trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ICU patient fell out of chair, evaluate for fracture or other\n traumatic injury.\n\n COMPARISONS: CT chest of .\n\n TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis with 150 cc of\n nonionic Optiray contrast per trauma torso protocol.\n\n CT CHEST WITH IV CONTRAST: The posterior aspect of the trachea is bowed\n greater than 50% with less than 8 mm AP dimension of the tracheal lumen,\n consistent with tracheomalacia on this nondedicated airway study. There\n remains diffuse lung disease, with persisting bilateral pleural effusions,\n loculated on the right. There are surgical sutures and scarring, presumably\n from prior right middle lobectomy. Diffuse ground-glass and alveolar\n opacities bilaterally, with additional septal fluid. These findings may be\n the residua of the previous pneumonia and ARDS per clinical history, but could\n also represent a component of volume overload/CHF. The heart is markedly\n enlarged. Again multiple significantly enlarged superior mediastinal and\n pericardial lymph nodes are noted, unchanged from the prior study. Dobhoff\n tube with its tip in the stomach.\n\n CT ABDOMEN WITH IV CONTRAST: No evidence of traumatic injury to the abdominal\n viscera. Gallstones without evidence of cholecystitis. Small retroperitoneal\n lymph nodes, none pathologically enlarged by CT criteria. A small, likely\n simple renal cyst in the left kidney, too small to characterize.\n\n CT PELVIS WITH IV CONTRAST: Foley catheter in a nondistended bladder. The\n rectum, sigmoid, and intrapelvic small bowel are normal. No abnormal lymph\n nodes in the pelvis.\n\n BONE WINDOWS: No evidence of acute fracture. Moderate degenerative change\n and demineralization. Stable lytic lesion involving the L3 vertebral body,\n unchanged from multiple prior CT's.\n\n IMPRESSION:\n\n 1. No evidence of traumatic injury throughout the chest, abdomen, and pelvis.\n\n 2. Extensive lung disease with bilateral pleural effusions, loculated on the\n (Over)\n\n 1:57 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: please evaluate for evidence trauma\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right. Additionally, there is diffuse ground-glass and alveolar opacities,\n which are slightly worsened compared to the CT of . These may relate\n to the ARDS, pneumonia given the previous clinical history, however, could\n also represent a component of CHF/volume overload.\n\n 3. Tracheomalacia.\n\n 4. Cholelithiasis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909530, "text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval effusions\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p extubation\n REASON FOR THIS EXAMINATION:\n eval effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:55 A.M. ON \n\n HISTORY: Extubation. Evaluate effusions.\n\n IMPRESSION: AP chest compared to chest films since , most recently\n :56 a.m.:\n\n Lung volumes remain quite low. Moderately severe pulmonary edema superimposed\n on bilateral consolidation has worsened accompanied by increasing moderate\n right pleural effusion. Cardiac silhouette partially obscured is at least\n moderately enlarged. Feeding tube ends in the stomach. Right central venous\n line tip projects over the SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-05-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910170, "text": " 4:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess chf /effusion\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p VATS.\n\n REASON FOR THIS EXAMINATION:\n assess chf /effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:24 A.M., ON \n\n HISTORY: Status post VATS. Pleural effusion.\n\n IMPRESSION: AP chest compared to and 30:\n\n A small-to-moderate right pleural effusion and the severity of diffuse\n infiltrative pulmonary abnormality which have been present for several weeks\n have both improved since indicating that some of these abnormalities\n can be attributed to recoverable fluid, however the longstanding nature of the\n abnormality suggests more than heart failure and pulmonary edema.\n\n Feeding tube ends in the stomach, right internal jugular line tip projects\n over the mid SVC. There is no pulmonary edema. Atelectasis persists at the\n site of right lung wedge resection.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909472, "text": " 11:46 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p DHT\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo F s/p extubation\n\n REASON FOR THIS EXAMINATION:\n s/p DHT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate Dobbhoff tube placement.\n\n COMPARISON: Comparison is made to study performed 2-1/2 hours earlier the\n same day.\n\n AP CHEST RADIOGRAPH: There has been interval placement of a Dobbhoff tube with\n tip seen coiled over the stomach. Again noted is a right-sided central line\n with tip overlying the SVC. Otherwise, no significant change is seen from\n prior study.\n\n" }, { "category": "Radiology", "chartdate": "2188-05-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 910408, "text": " 1:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for bleed\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p fall out of chair\n REASON FOR THIS EXAMINATION:\n Please evaluate for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old woman status post fall out of chair.\n\n TECHNIQUE: Head CT without contrast.\n\n COMPARISON: Comparison is made to the prior head CTs dated and\n .\n\n FINDINGS: Again note is made of a prominent area of hypodensity in the right\n occipital lobe, within the right posterior cerebral artery territory,\n reflecting prior infarction, unchanged compared to the prior study. There are\n also small hypodense areas in both cerebral ihemispheric periventricular white\n matter regions, representing chronic small vessel infarctions. There is no\n acute intracranial hemorrhage. The ventricles are symmetric and unchanged\n compared to the prior study. No shift of normally midline structures is seen.\n Again demonstrated is a 7-mm calcified lesion at the periphery of the left\n parietal vertex cortical surface, which may represent small meningioma,\n unchanged compared to the prior study. There is new opacification of both\n mastoid air cells. Again demonstrated is the hyperdense material with\n calcification within the left globe, unchanged compared to the prior study.\n There is mucosal thickening in left sphenoid sinus, likely inflammatory in\n origin.\n\n IMPRESSION:\n 1. Overall unchanged appearance of the brain, with prior infarction in the\n right occipital lobe as well as bilateral chronic small vessel ischemic\n changes in the white matter, as noted above.\n 2. 8-mm calcified lesion at the periphery of the left parietal vertex, most\n likely representing meningioma.\n 3. Opacification of bilateral mastoid air cells, likely inflammatory in\n origin.\n 4. Mild mucosal thickening in left sphenoid sinus air cell, again likely\n inflammatory in origin.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908181, "text": " 6:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pneumo, etc\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p R VATS wedge x3 RML\n REASON FOR THIS EXAMINATION:\n assess for pneumo, etc\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH\n\n HISTORY: Lung lesion. Status post right wedge resection times three right\n middle lobe.\n\n FINDINGS: Compared to the patient's preoperative PA and lateral views from\n five days ago, there is volume loss at the right lung base with a focal\n crescentic-shaped opacity at the operative site. Apparent widening of the\n upper mediastinum appears to be related to rotation. No pneumothorax is seen.\n\n CONCLUSION: Volume loss and atelectasis at operative site. No pneumothorax.\n (Note: Six interim films have been taken since this immediate postoperative\n study).\n\n" }, { "category": "Radiology", "chartdate": "2188-04-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908227, "text": " 9:58 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval s/p CT d/c\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with history of CVA and breast cancer now with multiple new\n lung nodules. Please note that patient has significant left sided weakness.\n s/pR vats , w/ Right CT/ tube placement, now d/c\n REASON FOR THIS EXAMINATION:\n eval s/p CT d/c\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post VATS, DC chest tube.\n\n CHEST, AP: Compared to the study from nine hours earlier, there has been\n interval worsening of bibasilar opacities, suggesting predominantly\n atelectasis. Probable right effusion. There are low lung volumes.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908304, "text": " 10:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for RML collapse\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p R VATS now w/ worsening pulm status\n REASON FOR THIS EXAMINATION:\n eval for RML collapse\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old female status post right VATS now with difficulty\n breathing.\n\n COMPARISON: at 10:00 a.m.\n\n UPRIGHT PORTABLE AP CHEST: The heart size and mediastinal contours are\n unchanged. There is persistent collapse of the right middle and likely right\n lower lobes. There is mild subsegmental atelectasis at the left base. No new\n focal areas of consolidation are identified. No pneumothorax.\n\n IMPRESSION: Persistent collapse of right middle and likely right lower lobes.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-04-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908522, "text": " 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for CHF, effusion, etc\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with history of CVA and breast cancer now with multiple new\n lung nodules.s/pRVATS middle lob wedge resection. Intubated for ^^\n secretions//S/p BAL - Please note that patient has significant left sided\n weakness.\n REASON FOR THIS EXAMINATION:\n Please assess for CHF, effusion, etc\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Postop right lung biopsy.\n\n Single AP film was obtained in limited inspiration. Positions of the ETT,\n left subclavian catheter, and NGT are unchanged since . Evidence of\n progressive perihilar edema particularly in the left since is noted.\n Numerous clips at the left base are present. There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908923, "text": " 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with history of CVA and breast cancer now with\n multiple new lung nodules.s/pRVATS middle lob wedge resection. Intubated\n for ^^ secretions//S/p BAL - Please note that patient has\n significant left sided weakness.\n\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old female with history of breast cancer status post right\n middle lobe resection.\n\n COMPARISON: .\n\n AP supine portable chest: The endotracheal tube and left subclavian central\n catheter remain in appropriate positions. The nasogastric tube courses over\n the left upper abdomen out of field of view. There is asymmetric air space\n opacity, left greater than right, probably a combination of pulmonary edema\n and superimposed left upper lobe pneumonia. There are small if any pleural\n effusions. No pneumothorax. Mediastinal widening is unchanged and likely due\n to vascular engorgement.\n\n IMPRESSION: Bilateral pulmonary edema and left upper lobe pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2188-04-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908448, "text": " 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with history of CVA and breast cancer now with multiple new\n lung nodules.s/pRVATS middle lob wedge resection. Intubated for ^^\n secretions//S/p BAL - Please note that patient has significant left sided\n weakness.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:00 A.M., \n\n HISTORY: CVA and breast cancer. New lung nodule. VATS and _____.\n\n IMPRESSION: AP chest compared to and 13:\n\n Perihilar opacification greater on the left and generalized hazy opacification\n of the lungs has developed since . In the setting of persistent\n cardiomegaly and mediastinal vascular engorgement, this is most likely edema.\n Small right pleural effusion, partially fissural persists. Right lower lobe\n collapse has improved. ET tube and left subclavian central venous line are in\n standard placement and a nasogastric tube passes below the diaphragm and out\n of view. No pneumothorax.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2115-04-30 00:00:00.000", "description": "Report", "row_id": 310594, "text": "Sinus tachycardia with a left axis deviation. Poor R wave progression. Compared\nto the previous tracing of the rate has increased.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2174-03-25 00:00:00.000", "description": "Report", "row_id": 1510318, "text": "ROS:\n\nNeuro: Cisatracurium weaned off. Midaz weaned down to 2.5. Fentanyl at 30 mcg. Facial grimicing w/oral cares and painful stim. PERRLA.\n\nCV: Afib rate 60-76, dig 0.125 iv at noon as scheduled. Has left femoral Triple Lumen. Has right femoral IABP on 1:1 w/good augmentation and fair unloading. Has right femoral SWAN. PA in RV, advanced by Karthic to 70 cm. Thermodilution CO w/marginal CI, At times when CI < 2.0 FICKs checked and CI then > 2. See flow record for hemodynamic details. TEE done which showed no vegitation and known flailing posterior MV leaflet. Left radial abp line dampend towards end of this shift. P boots added today for DVT prophylaxis. Heparin gtt decreased to 700 U/hr. Vasopressin on at 2.4 U/hr. Levophed weaned to 0.08 mcg/kg/min.\nPeripheral pulses in LE dopplerable.\n\nResp: Remains orally intubated and on vent. Vent weaned to AC 500x18, peep 12, 40%. Sats 98%. Lungs clear, sx thick bloody secreations. Has bilateral chest tubes to 20cm sx draining straw colored fluid in large amts. No resp distress noted, = rise and fall of chest.\n\nGI: Abd soft w/o bowels sounds. Has sump via right nare to lcs draining bile. Protonix for GI prophylaxis.\n\nGU: foley patent draing clear amb urine in marginal amt.\n\nEndo: Insulin gtt titrated per CSRU RSSI protocol.\n\nLytes: K repleted multiple x's this shift. IC repleted x's 1.\n\nSocial: Daughter and wife in this afternoon. Very supportive.\n\nPlan: Titrate levo to keep SBP 90-100. Check FICKs PRN. IABP 1:1. New peripheral ABP line. Check PTT at 2200. Follow lytes closely and replete PRN. Pulmonary toileting. Lighten sedation for neuro exam if tolerates. Monitor, tx, support,and comfort. OR Monday.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-26 00:00:00.000", "description": "Report", "row_id": 1510319, "text": "Neuro: Pt. sedated with versed & fentanyl but responds to irritable stimuli ie: ETT sx, oral care, subglottal sx. Pt. moves head side to side and bites down on sx. cath. PERL.\n\nCV: hemodynamics improved with pt. converting to NSR. CI 2.5. BP by radial aline not accurate due to dampening. Following IABP central BP.\nIABP at 1:1 with good augmentation. Adequate diast & syst unloading. Peripheries warm with good cap. refill. All distal pulses strong by doppler. No IABP alarms. remains on Levophed & Pitressin.\n\nPulm: SX for bloody secretions. Noted that sao2 drops to 91-92% and quickly recovers after pre- oxygenation with 100% and sx. BS essentially clea. Bilat chest tubes still drng. fair amounts straw colored fluid. No air leaks detected. ABG's WNL.\n\nGI: Bilious gastric drng from OGT/ No stool this shift.\n\nGU: Adeuate HUO avg. 60cc/hr.\n\nSkin: No breakdown noted upon repositioning. Line insertion sites with occlusive dsg's. Lower extr. aligned with multipodus splints.\n\nID: flagyl. vanco, ceftriaxone. afebrile.\n\nPlan: Replete lytes prn. Monitor for arrhythmias in view of hx afib.\nMonitor coags in the setting of heparin therapy. Plan for OR on monday. maintain adequate gas exchange with vent settings. monitor IABP fx and hemodynamics.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-30 00:00:00.000", "description": "Report", "row_id": 1510339, "text": "To OR this AM for MVR. Tissue sent to pathology. 2L crystoloids, 2 UPRBC, CX 40\", CPB 52\", OUt on epi, levo, vasopressin, and propofol.\n\nROS:\n\nNeuro: Reversal agents not given, as the plan is to leave sleep. Propofol for sedation at 30 mcg/kg/min. Opens eyes to aggressive cares and tx. PERRLA.\n\nCV: RSR w/o ectopy. VSS. Has new right radial ABP line. Has left subclavian cordis w/CCO swan. SVO2 70's. CO/CI 5.2/2.5. See flow record for hemodynamic details. IABP weaned and dc'd, site w/small hard hematoma, slightly larger then an egg. Peripheral pulses palpable. Has 2 mediastinal chest tubes, Y connected together and to 20 cm sx H2O seal draining thick chunky blood in small amt. Bilateral pleural chest tubes also Y connectected together to 20 cm sx draining sang fluid in small amts. Sternal and mediastinal drsg . Has 2 A and 2 V epicardial pacing wires, Both sense and capture. P boots for DVT prophylaxis.\n\nResp: Remains orally intubated and on vent, SIMV 650x18, peep 10, ps 10, 60%. Lungs clear and diminished. Sx ETT for thick bloody secreatins. Pleural chest tubes as noted above. No resp distress noted, = rise and fall of chest.\n\nGI: Oral sump to LCS draining scant clear. Xray shows need for advancement as tip is just past G/E junct. Attempts made to advance OG w/o success. Carafate for GI prophylaxis.\n\nGU: Foley patent draining clear yellow urine in QS. Creat down to 1.9 post OP.\n\nEndo: No coverage required of FSG\n\nLytes: K 4.2, repleted w/20 kcl. IC 1.08, repleted w/2 GM Ca Gluc.\n\nSocial: Wife updated several times today. Not comming in d/t road conditions.\n\nPlan: SBP > 90, MAP > 60. Leave Vasopressin at 2.4 and titrate levo as necessary. Pulmonary toileting. Wean vent as able. Mobilize. Monitor right groin ? hematoma. Monitor, tx, support, and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-31 00:00:00.000", "description": "Report", "row_id": 1510340, "text": "Respiratory Therapy\npt prresents orally intubated on SIMV 15/10. BS initially coarse later, diffuse wheezes. Combivent and flovent ordered and given w some improvement. Sx for small to moderate amount thick mainly bloody secretions. Weaned peep to 7 pt became more arousable and disynchronous, increased MAP, went into RAF. Pt medicated, placed on PSV with good effect on respiratory status and vent synchrony. MD of vent changes. Plan: continue to assess readiness to extubate, wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-04 00:00:00.000", "description": "Report", "row_id": 1510351, "text": "NEURO: alert, O to and hospital. still mumbles and with rambling conversation, perseverating on ideas. MAE, upper extremities lift and fall, LE's move on bed. strength improving. PERRL.\nCV: a fib 80's-100. SBP 110's-130. tolerating vasotec, lopressor, lasix IV. diuresing to lasix. generalized edema. DP/PT palp. started on amio gtt 0.5 mg d/t not able to take amio PO dose. heparin gtt decreased for supratherapeutic PTT. next PTT due 1100.\nRESP: lungs diminished bilat. bases. ABG stable on face tent 50% d/t mouth breather. chest tube and R chest tube site continue with serosang drainage drainage bag to R chest intact. ?aspiration with meds crushed in applesauce.\nGI/GU: abd soft, +bowel sounds. had liq brown BM. dophoff and sump NG tubes attempted, unsuccessful. foley with clear yellow urine.\nENDO: blood glucose not requiring RISS coverage\nSKIN: to coccyx red, slightly smaller area over the weekend with aloevesta/antifungal cream. sternal incision and mediastinal chest tube dsd changed. coccyx reddened. MP boots, SCD on.\nLINES/ACCESS: cordis L subclavian reddened, positional when pt turned on L side.\nSOCIAL: no calls this shift.\nA/P: continue to monitor cv, resp., continue diuresis, monitor mental status and reorient . PTT due at 1100. OOB to chair with . Needs NGT placement ?IR. cordis change to 3 lumen.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-04 00:00:00.000", "description": "Report", "row_id": 1510352, "text": "Neuro: alert confused to place at times, knows person and time, denies pain, pupils are equal and reactive to light, mae though is weak in all extremities, did get oob to chair with lift, is taking po's with no signs of asperation-is in for swollow reval due to patient did fail swollow test on friday.\n\nCardiac: afib, continues amio gtt, hep gtt shut off in am for high ptt, ptt now normal but awaiting md to come change cordis over to triple lumen, palpible pedial pulses, skin warm dry and intact, afebrile, +1 edema in extremities, is on coumadin po.\n\nResp: weaned to 4 liters nc and abg is wnl's, lungs are dim in bases bilat, ct system to sxn draining moderate amounts of serosang and is + for air leak.\n\nSkin: chest with dsd that is , ct dsd is , left dsd is , right side old ct site draining small amounts of serous, does have yeast on back and topical miconozole powder applyed, has venodymes and multipodis boots on.\n\nGi/Gu: ng tube on hold for patient is now swollong with no difficulty and no signs of asperation, ? will need in future if patient does not take in enough po's, does have poor appetite and needs encouragment to eat, is also unable to lift hands to mouth to eat and needs assist, has good bowel sounds, abd is soft round and nontender, loose brown stools-c-diff sent, on riss, is making good u/o with lasix.\n\nSocial: family in to visit and updated.\n\nPlan: wean o2, encourage to eat, encourage to do arm and leg exersises while in bed, change cordis to triple lumen, ? ng tube in future if does not take in adequate po's, ? restarting heparin post line change.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-11 00:00:00.000", "description": "Report", "row_id": 1510371, "text": "shift cover 0700-1500\n\nneuro: pt awake. perla. maex4 to command w equal strenght. though very weak. no deficit. mouthing words and write words on board appropriate. sl apprehensive about and status. need reinforcement and emotional support with effect.\n\nid: febrile. no cx np. last cx on and pnd. con't multi abx. sent vanco trough in am. to give tynelol after ultrasound np\n\ncv: afib 120s-130s w sbp 120s-130s-give full dose lopressor 15mg ivp x2 due schedule np -w effect-rate down to 100s now. no ectopies. amiodarone gtt at .50. con't anticoagulate with heparin gtt- ^ for subtherapeutic level. need PTT at 1600. con't replete k -^kdur po scheduled. diuresis w lasix. skin w/d. peripheral edema, non-pitting.\n\nvasc: both feet and legs w/o discoloration-warm and palpable pulses. cap refill <3sec\n\nresp: remained on cpap .40/5/8peep. vt 400s-500s. gas pao2 130s and resp alkalosis. rr high 20s -30s related to anxiety?. no vent change np . sl diminish throughout. cxr in am w evident of infiltration/pleural effusion-see report. plan for bronch/trach/left CT placement tomorrow. vap protocol\n\ngi: tf clamped. npo for us in pm. c/o belly pain in ruq and rlq->described \"dull\" intermittently-->sent amylase/lipase/lfts -u/s in pm\n\nendo: no coverage d/t npo\ngu: diuresis via foley. +bs. attempted bedpan w/o success. colace. ?need more regimen\nwound; see careview. coccyx -redden, stage 1ulcer-->reposition, applied miconizole cream. pneuo boots. multipodus boots\ncomfort: ultram for pain. family at bs->update status. support pt\n\na/p: NPO after midnoc for trach/bronch/left ct placement/peg tomorrow. need d'c heparin after midnoc. f/u cx and ptt. control rate/bp. monitor labs/belly pain.resp hygiene. vap. support.restart tf after us\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-04-11 00:00:00.000", "description": "Report", "row_id": 1510372, "text": "Respiratory Care\n\n Pt continues on CPAP/PSV in NARD. B/S sl coarse sx'ing sm/mod thick white. Plan: trach and peg tomorrow. Will continue to follow .\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-25 00:00:00.000", "description": "Report", "row_id": 1510316, "text": "ALTERED RESPIRATORY STATUS\nO: CARDIAC: AF 130'S-110'S TO PRESENTLY 70'S+60'S. ^ VEA WITH DIURESIS,0630 K 3.5 20 MEQ KCL UP AND INFUSING. SBP GOAL 100, VASOPRESSIN WEANED TO 2.4 UNITS AND HAS REMAINED THERE. LEVO AT .14 MCQ. HEPARIN UP AT 0030, 0630 PTT PENDING. IABP 1:1 WITH SOME UNLOADING. DOP PP. FEET SLIGHTLY COOL. HANDS AND BODY IS DRY. RIGHT GREAT TOE IS DUSKIER THAN REST OF RIGHT TOES. LEFT TOES SLIGHTLY DUSKY, FEET PALE. RIGHT FEM SWAN +IABP SITE C+D. LEFT CT DRAINING SEROSANGUINOUS DRAINAGE, RIGHT CT DRAINING STRAW COLORED DRAINAGE LARGE AMOUNTS. CXR QUITE IMPROVED AFTER CT PLACED. PADS TWENTIES. CVP LOW TEENS. WEIGHT 107.6 ? UP 20 KG FROM RECORDED ON ADMISSION.HCT 30. RECEIVED 2 GM CALCIUM X1. MAG NESIUM WNL.LACTATE ON THE RISE 2.8. CI <2 WITH MVO2 >60.\n RESP: VENT SETTINGS+ABG PER FLOW. SUCTIONED FOR BLOODY SPUTUM-C+S SENT. BS DIMINISHED BIBASILAR, CLEAR UPPER. NO CHEST TUBE LEAKS. O2 SATS >97%. PRESENTLY ON CMV >40,TV500,RR29,12 PEEP. ETT ROTATED TO LEFT SIDE OF MOUTH.\n NEURO: PARALYZED ON CISATURCURIUM ^ TO .18 WITH 3 EYELID TWITCHES. PERL PINPOINT EQUAL AND BRISK.\n PAIN: FENTANYL AT 30 MCQ AND VERSED AT 5 MG/HR.\n GI: OGT DRAINED 50 ML BILIOUS DRAINAGE, ABD SOFT, ABSENT BOWEL SOUNDS. NO STOOL.\n GU: RECEIVED 40 MG IVP LASIX WITH EXCELLENT DIURESIS, CREAT .9, UA C+S SENT.\n ENDO: INSULIN GTT AT 10 UNITS/HR WITH GLUCOSE 117\n ID: VANCO, FLAGYL, CEFEPIMINE, ADMINISTERED AS PER ORDERS. PANCULTURED . TEMP 35.7 BAIR HUGGER TO BE APPLIED.\n SOCIAL: WIFE AND DAUGHTER INTO SEE PT AND UPDATED, WIFE WILL BE THE SPOKESPERSON.\nA: BETTER OXYGENATION, HR SLOWER CONTINUES IN AF, ABLE TO WEAN LEVO AND VASOPRESSIN, DIURESED,\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-GOAL TO KEEP 100-WEAN LEVO AS TOLERATED-KEEP VASOPRESSIN AT 2.4 UNITS/HR, CI, MVO2, PADS,CVP, CT DRAINAGE, RESP STATUS, NEURO STATUS-TOF, I+O, LABS. AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-25 00:00:00.000", "description": "Report", "row_id": 1510317, "text": "Respiratory Care Note\n Pt received on AC as noted. BS clear, but diminished in the bases. Vent settings weaned according to ABG's. ABG at end of shift within normal limits. Pt had a TEE - results pending. Plan to remain intubated and mechanically ventilated. Plan to continue to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-28 00:00:00.000", "description": "Report", "row_id": 1510327, "text": "NEURO-FACIAL GRIMACING WITH PAINFUL STIMULI.BITING ON ETT WITH SXING AND ORAL PURPOSEFUL MOVMENT OR RESPONSE. MOVES HEAD SIDE TO SIDE. LOWER EXTREMITIES MOVED SLIGHTLY X1. NO UPPER EXTREMITY MOVEMENT SEEN.BODY FLACCID. HAD 1 SPONTANEOUS EPISODE OF ^HR-AFIB>140, RR^ 35-40 SATS DECREASED TO 92%. HEAD THRASHING SIDE TO SIDE,EYES OPENED. NOTIFIED AND ORDERED 1MG IVP HALDOL X1 MR X1 IF NEEDED. GOOD EFFECT WITH 2MG IVP HALDOL.HR/RR/SATS RETURNED TO BASELINE.\n\nCV-CONTINUES IN AFIB. LEVO/VASOPRESSIN FOR BP SUPPORT TO KEEP SBP 100-120.IABP 1:1 WITH AUGMENTATION.\nHEPARIN GTT @600U/HR. PTT PENDING.AFEBRILE. DIAPHORETIC.+PP. GENERALIZED BODY EDEMA.\n\nRESP- CMV-> CPAP/PS BECAUSE OVERBREATHING RATE. TOLERATED CPAP/PS WITH INCREASES MADE IN PS/FIO2 DURING TACHYPNEIC EPISODE. ABG WNL. LS CLEAR UPPERS/DIM BASES.SXING THIN DARK RED BLOODY SECRETIONS. CT DRG THIN STRAW COLERED FLUID. RT> LT. RT CT DSG SATURATED WITH CLEAR FLUID. LT CT DRY. MOD. AMT CLEAR THICK ORAL SECREITONS.\n\nGU- ABD SOFT. NPO. UNABLE TO HEAR BS D/T IABP.\n\nGI- ADEQUATE HOURLY U/O UTNIL 0200 THEN DECEASING DOWN TO 35->25 CC/HR. PA NOTIFIED. 500CC NS BOLUS GIVEN WITH EFFECT.\n\nLABS-K+ REPLETED PRN. CA+ GLUC. LEVELS WNL.\n\nPAIN- GRIMACNG WITH PAINFUL STIMULI THE SUBSIDES.\n\nPLAN- ?EEG TO EVALUATE NEURO STATUS RE: NOT WAKING UP FROM PREVIOUS SEDATION.?CONT. TO MONITOR NEURO STATUS,HEMODYNAMICS, ?WEAN IABP?\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-28 00:00:00.000", "description": "Report", "row_id": 1510328, "text": "Respiratory Care: Pt currently on PSV 20/P10 50%. Had episodes of tachypnea and ^HR. Placed initially on AC to settle pt, but eventually placed back to PSV with increase to 20. Still appears restless with ^RR. Pt had CT of head last night to check neuro status, and will have neuro workup today. No RSBI measured this am due to peep level. Suctioned small amt blood, otherwise clear secretions.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-28 00:00:00.000", "description": "Report", "row_id": 1510329, "text": "Resp. Care Note\nPt received intubated and vented on PSV settings as charted on resp flowsheet. PSV level weaned to 15 today with TV 700's and ABG's stable. Pt bronched this morning due to BRB from ETT. No source of bleeding found on bronch. Pt following commands now. Plan is to cont current vent settings, no plans to extubate, anticipate surgury soon.\n" }, { "category": "Radiology", "chartdate": "2174-04-20 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 951814, "text": " 1:45 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: r/o aspiration\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p mvr\n REASON FOR THIS EXAMINATION:\n r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Please rule out aspiration.\n\n Video fluoroscopic images were obtained with assistance speech pathologist.\n Barium of various consistencies was given to the patient. No aspiration or\n penetration was seen. Delayed emptying of valleculae and piriform sinuses was\n seen most likely secondary to patient's weakness. Please look at the speech\n pathologist's report in CCC for complete assessment and recommendation.\n\n IMPRESSION:\n 1. No aspiration or perforation is seen.\n 2. Slight retention of barium within the valleculae and piriform sinuses most\n likely secondary to patient's weakness.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 951945, "text": " 1:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrates/effusions\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR with high WBC, FTW and pleural effusion.\n\n REASON FOR THIS EXAMINATION:\n assess for infiltrates/effusions\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMIERECT CHEST.\n\n COMPARISON: .\n\n INDICATION: Elevated white blood cell count.\n\n A tracheostomy tube and central venous catheter remain in place. Cardiac and\n mediastinal contours are within normal limits. Focal consolidation in the\n right upper lobe is unchanged allowing for differences in patient positioning,\n but has improved compared to an older study of . Additional\n multifocal areas of consolidation in the left upper and both lower lobes show\n interval improvement compared to the recent radiograph with residual opacity\n most prominent in the left lower lobe. Small left pleural effusion has also\n slightly improved.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-01 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 948956, "text": " 8:58 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? left hemothorax\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p VR\n REASON FOR THIS EXAMINATION:\n ? left hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP VIEWS OF THE CHEST (TWO).\n\n COMPARISONS: Prior study performed four hours before.\n\n REASON FOR EXAM: Question left hemothorax. Patient is AVR.\n\n FINDINGS:\n There is no pneumothorax. Small bilateral pleural effusions are unchanged.\n Moderate to severe pulmonary edema, worse in the right side is unchanged.\n Cardiac size is normal. No other changes compared from prior study performed\n four hours before.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-28 00:00:00.000", "description": "Report", "row_id": 1510330, "text": "Neuro: woke this am and mae to command, did also stick out toungue to command, pupils equal reactive to light, started low dose prop to keep comfortable.\n\nCardiac: chronic a/f at baseline in one teens-team did attempt 2.5 iv lopressor which did not work too good, left subclavian cco swan placed and ci's and svo2's all wnl's, did pull bilat fem central lines and tip cultures sent, iabp remains in place, continues levo, pit gtt's with no change, did have heparin gtt off in am for line change, restarted hep back at 600 at 1500-need ptt at 2100, palpible pedial pulses, skin warm and diaphoretic, temps around 99, palpible bilat upper extremites pulses, +2 edema in extremities.\n\nResp: lungs dim in bases bilat, on cpap with good abg's did wean down p.s. to 10, bilat ct system draining moderate amounts of straw ct drainage, no air leak in both ct systems.\n\nSkin: bilat ct dsd changed for small amount of serous drainage, ballon site with transparent dsd is cdi.\n\nGi/Gu: restarted tf's at 40/hr, good bowel sounds, abd is soft round and nontender, on riss, makinf small amounts of ambeurine with sediment that was sent for culture-did also start lasix which patient did not respond to well too.\n\nSocial: wife and kids in to visit and updated.\n\nPlan: continue prop gtt, continue pit and levo gtt, monitor heart rate, u/o, bp, iabp, resend ptt at 2100.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-29 00:00:00.000", "description": "Report", "row_id": 1510331, "text": "UPDATE\nNEURO: PT LIGHTLY SEDATED @ BEGINNING OF SHIFT: EYES OPEN(L>R), ABLE TO NOD HEAD TO QUESTIONS(DENIED PAIN) AND GRASP WITH HANDS. SEEN TO MOVE L TOES TO COMMAND ONLY. BECAME MORE RESTLESS AND TACHYPNEIC OVER NEXT FEW HRS SO PROPOFOL TITRATED UP TO 30 MCG/KG/MIN. P.A. NOTIFIED. RR DOWN TO 20'S AND HR DOWN TO 110'S.\n\nCV: AFIB RATE 120-130 @ BEGINNING OF SHIFT W/ RARE PVC'S; NOW LOW 100'S AFTER 2 DOSES IV LOPRESSOR(0400 DOSE HELD DUE TO SBP<100). PVC'S RESOLVED AFTER KCL GIVEN. LEVOPHED WEANED SLIGHTLY. TRYING TO KEEP SBP>100 PER . C.I. 2-3 RANGE W/ SVO2 62-70%. IABP CONT ON 1:1 SETTING, NO PROBLEMS. TAKEN ON ARMS. R(138/54) IS SIGNIFICANTLY HIGHER THAN L(107/46).\n\nRESP: DIMINISHED LS L SIDE, COARSE ON R. SUX FOR MOD AMTS THICK BLOODY PLUGS. PAO2 IMPROVED ON RECENT ABG TO 150 W/ MILD METAB ALKALOSIS. CONT ON CPAP DURING NIGHT. IPS DROPPED TO 10 FOR ALKALOSIS BUT PUT BACK TO 15 DUE TO TACHYPNEA. RR CURRENTLY 22, SPO2 98%.\n\nG.I.: TF STOPPED @ MN FOR IMPENDING OR THIS A.M., NGT CLAMPED.\n\nG.U.: BORDERLINE UO WHICH PERSISTED AFTER LASIX LAST EVE AND AGAIN THIS A.M. BOTH TIMES FOLEY IRRIGATED W/ 90 L NS (WITH SL DIFFICULTY) FOLLOWED BY INCREASED UOP. LIGHT SEDIMENT IN URINE, NO CLOTS.\n\nI.D.: TEMP SPIKE TO 101.8 F DURING NIGHT. NOTIFIED AND BLD CX X2 DRAWN. PREVIOUS BLD CX RESULTS PENDING. WBC UP TO 27.6 THIS A.M.(UP FROM 19). PR TYLENOL GIVEN. CONT ON IV VANCO/CEFTRIAXONE. PRE-OP 2% CHG SCRUB DONE.\n\nENDO: SSRI FOR GLUCOSE CONTROL. NEEDING LESS THIS A.M. NOW THAT TF OFF.\n\nSOCIAL: PHONE CONSENT GIVEN BY WIFE FOR SURGERY/ANESTHESIA LAST NIGHT.\n\nA/P: PLAN IS FOR PT TO HAVE MV REPAIR OR REPLACEMENT IN OR TODAY BUT UNSURE IF TEAM WILL GO AHEAD GIVEN ELEVATED TEMP/WBC. WILL DISCUSS ON A.M. ROUNDS. MEANWHILE, TF AND IV HEPARIN OFF. HEMODYNAMICALLY STABLE WITH IABP AND PRESSOR SUPPORT. NEED ABX ADJUSTMENT ONCE CX RESULTS FINAL. APPEARS NEUROLOGICALLY INTACT BUT OCC RESTLESS. MONITOR GLUCOSE, LYTES CLOSELY. REPEAT ABG.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-29 00:00:00.000", "description": "Report", "row_id": 1510332, "text": "Respiratory Care Note:\nPatient spiked temp lastnight with WBC over 27. CXR with persistent alveolar opacities, R>L. BS coarse bilat. Suctioned for bloody secretions- heparin recently discontinued. He remains on levo, pit and prop infusions. Plan was for OR today, will continue to provide vent support and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-29 00:00:00.000", "description": "Report", "row_id": 1510333, "text": "BS coarse crackles. Suctioned for thick bloody secretions. Switched to MMV due to repeated apnea spells. MVR not done today due to general septic presentation, ? tomorrow. Afebrile now but no current WBC>\n" }, { "category": "Nursing/other", "chartdate": "2174-03-30 00:00:00.000", "description": "Report", "row_id": 1510337, "text": "BS CTAB. To OR today for MVR. BS few coarse crackles. Wean from vent per CSRU protocol.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-30 00:00:00.000", "description": "Report", "row_id": 1510338, "text": "Correction: A wires sense but do not capture.\nEpi weaned off early w/^SVO2\nMediastinal drsg w/small sang drng.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-31 00:00:00.000", "description": "Report", "row_id": 1510342, "text": "ROS:\n\nNeuro: Lightly sedated on propofol 10mcg/kg/, x's 4 to command. Nods head yes/no to questions asked. PERRLA. Percocet via OG for pain mngt w/good effect.\n\nCV: AFIB rate 100-120. Had 6 beat run of VT this AM. On amiodarone gtt, rate decreased to 0.5 at 1300. Vasopressin at 2.4 units/hr. Levo weaned this afternoon, currently at 0.04 mcq/kg/ on to keep MAP >60 and SBP > 90. Has 2 A and 2 V epicardial wires connected to pacer for back up pacing. Both A and V wires sense. Capture not checked d/t AFIB and ^ HR. Hx of A wires not capturing. Has 2 mediastial and 2 pleural chest tubes. Meds Y connected together and Pleurals Y connected together both draining thin sang fluid in small amt. Sternal and mediastinal drsg . Generalized edema. Peripheral pulses palpable w/ease. Has Right radial ABP line. Has left subclavian cordis w/CCO SWAN, CO >5/CI >2. P boots for DVT prophylaxis.\n\nResp: Remains orally intubated and on vent, CPAP currently , 50%. Sats 95% or >. Lungs clear and diminished in the bases. Sx ETT for thick bloody secreation. Bilateral pleural CT as noted above. Old chest tube sites draining serosang -> sang fluid. Drsg .\n\nGI: Oral sump to lCS draining small amt of bile. Abd soft w/hypoactive BS. Protonix and carafate for GI prophylaxis.\n\nGU: Foley patent draining clear yellow urine in marginal amt.\n\nSkin: Localized prickly like red rash on buttocks.\n\nEndo: FSG covered w/RSSI SQ\n\nLytes: K 4.1, repleted w/20 kcl. IC also repleted.\n\nSocial: Wife and daughter in this afternoon for visit, supportive.\n\nPlan: Wean levo as BP tolerates. Deline in AM. Remain on CPAP 5/5 as long as tolerates, many need to rest on rate over noc. Pulmonary toileting. Maybe extubate in AM??? Mobilize, monitor, tx, support and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-31 00:00:00.000", "description": "Report", "row_id": 1510343, "text": "resp. care\npt. remains intubated/vented. off sedation. vent\nweaned to ps 5/5 with good abg. mdi's given. ?\nextubate in a.m.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-01 00:00:00.000", "description": "Report", "row_id": 1510344, "text": "Nursing Progress Note:\nNeuro: When propofol gtt off- Pt opens eyes spontaneously. Perl 4mm brisk. MAE. Follows commands. nods to yes/no questions.\n\nCV: Afib. HR 100's. Pulses palpable. Tmax 100.2. SVO2 70's, CI >3. PAD 20, CVP >10. Sternal and mediastinal dressings . A and V wires intact. Unable to check capture due to HR >100. K repleted. Mediastinal with minimal sanguinous drainage. Peripheral edema.\n\nResp: PS increased to 12 overnight to rest pt. Placed back on cpap 5/5/50% Suctioned for small amount of thick, blood-tinged secretions. Rt pleural CT with minimal serosanguinous drainage. Old (rt/lt) thoracotomy sites oozing moderate amount of serosanguinous drainage. Lungs CTA decreased at bases. Sats 99%\n\nGI/GU: Abdomen soft, nondistended. BS present. OGT to LCS. Minimal bilious drainage. Foley changed d/t low UO and increased sediment in catheter. After new foley insertion, pt drained 1L of urine.\n\nEndoc: RISS\n\nID: Zosyn and Vanco. Vanco level pending\n\nPlan: Extubate today. De-line. Monitor hct and lytes. Wean vasopressin. Start PO amio? OOB to chair. Pain management.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-07 00:00:00.000", "description": "Report", "row_id": 1510359, "text": "from OR\nFrom OR at 0815, report received from anesthesia; embolization of the lumbar artery done; received 6units platelets, 1unit ffp, 3 units prbc. intubated, initially acidotic, improved with lasix and increased rate/peep. see flowhseet for abg's and vent settings/changes. sedated on prop gtt, +PERRL. SR without ectopy, on and off levo to keep map>70. RLE cooler than the LLE, pulses are dopplerable to RLE, palpable LLE.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-07 00:00:00.000", "description": "Report", "row_id": 1510360, "text": "7a-7p addendum\nneuro: off prop gtt, groggy, arousable to voice, opens eyes spontaneously, oriented x3. MAE with equal strength, follows commands. +PERRL. denies pain.\n\ncv: SR at the beginning of the shift, off levo gtt after extubation. into A-fib 110-130 at ~1230, rate down to 90-110 after metop 5mg ivp x2, amio bolus x2. amio gtt started at 1700. po metop increased to tid. RLE pulses are dopplerable, cooler than the LLE; LLE pulses are palpable. exercising in bed with PT.\n\nresp: ls clear, dim at bases. extubated. o2sats 93-95% on face tent 80%, team aware, extra 20mg ivp lasix given. IS up to 500, poor cough effort, needs encouragement, chest pt done.\n\ngi/gu: abd soft, distended, +bowel sounds. no stool today. started ice chips tonight. indwelling cath draining amber color urine, sufficient quantities, diureses with lasix.\n\nendo: RISS\n\nplan: aggressive pulmonary toilet!!!! continue to monitor hemodynamics, continue amio gtt, continue metop.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-08 00:00:00.000", "description": "Report", "row_id": 1510361, "text": "Neuro: pt A&0 X3, MAE's but has some ROM difficulty D/T edema, denies pain nor discomfort, follows commands, forgetful at times\n\nResp: LS clear but diminished at bases, CPT X3 with good results, IS, cough and deep breathing reinforced with good results, O2 via face tent\n\nCardiac: SR, no ectopy noted, BP and HR stable\n\nGI: + BS all 4 quads, no flatus, no BM, pt had significant cough after sips of nectar thick liquids, MD notified, NPO for now, held AM lopressor until futher orders\n\nGU: foley to gravity drainage draining clear yellow urine > 50cc/hr, lasix \n\nEndo: SSRI coverage pe \n\nSocial: pts wife called and updated on condition\n\nPlan: pulmonary toilet, CPT, monitor labs and vitals and treat as indicated and as ordered, ? swallow evaluation, ? deline and transfer to 2\n" }, { "category": "Nursing/other", "chartdate": "2174-04-11 00:00:00.000", "description": "Report", "row_id": 1510369, "text": "Nursing Progress Note:\nNeuro: Follows commands. MAE. Communicates by nodding head and hand gestures. Perl 3mm brisk. Impaired gag. Coughs when suctioned.\n\nResp: LCTA decreased bases. Sats 99% on cpap 5/8/40% Suctioned for minimal amount of thick, yellow secretions. Metab alkalosis.\n\nCV: Afib. HR 80-100's. NO ectopy noted. ABP 100/50's. Neo weaned off. Pulses palpable. Rt great toe color and temp improve. NTG gtt applied to Rt great toe. Sternal and mediastinal . K repleted. Heparin gtt at 1000u/hr. PTT 68.\n\nGI/GU: Abdomen soft, flat. BS +. Impact at 40cc/hr. minimal residual. Foley cath. Good UO.\n\nID: Vanco, zosyn\n\nPlan: To OR on Tuesday for T&G, Bronch. Monitor lytes and hct.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-11 00:00:00.000", "description": "Report", "row_id": 1510370, "text": "Respiartory Care Note:\n\nPt ren=main orally intubated & sedated on spontaneous ventilation. No vent changes done. RSBI done ~65. Bs are dim with some rhonchi. Wea re sxtn for small amt of thick yellowish. Plan: Bronch and trach & Peg tomorrow & keep confortable. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-08 00:00:00.000", "description": "Report", "row_id": 1510362, "text": "See and carevue for detailed documentation\n\nNeuro: Pateint alert, oriented x3, occassionally slow to respond, does well with redirection. MAE. c/o decreased sensation in LLE, normal movement. Denies pain. Anxious thru shift. Difficult to redirect at times.\n\nResp: In 5L NC, 60-80% face mask. PaO2 70-90. Tachypneic 30-40's. Attempt to give patient water, soft solids with ?aspiration. Acute deSAT to 70's, slow to recover. NP suctioned, unable to cough up secretions. Poor gag. Patient again with deSAT to 70's with attempt to place NGT. Slowly recovered with SAT >95%, remianed tachypneic to 30's. BS clear->slight coarse, diminished in bases. CPT x2 with minimal result. CXR with pulmonary edema despite increased lasix dose.\n\nCV: Remains in afib HR 90-120 with rare PVCs, BP 120-170/50-70 despite frequent lopressor doses. Potassium and calcium remain low despite repletion. Rec'd patient with R foot with doppler pulses/ Later no DP pulse on R, PT found by doppler. LE US done, minimal flow to R foot below ankle. Heparin gtt started, nitro ointment to skin. Vasculat team to follow.\n\nGI: NPO, unable to tolerate anything by mouth without ?aspiration. Attempt to place feeding tube without result. No BM/ flatus.\n\nGU: Foley to gravity with large amounts urine with sediment s/p lasix.\n\nEndo: RSSI, no coverage needed for shift.\n\nSocial: Spouse and daughter to visit. Supportive of patient. anxious with decreased flow to foot. Updated by CSRU team and vascular team.\n\nPlan: Continue cardiopulmonary monitoring. Continue pulmonary toilet, O2 supprt. Wean if tolerated. STRICT NPO, continue to reeval for po tolerance. Continue to reassure, anxiety.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-09 00:00:00.000", "description": "Report", "row_id": 1510363, "text": "Nursing progress note:\nNeuro: AAO x3. Pt anxious. Weak cough. ABle to lift and hold upper extremeties. Moves lower extremeties.\n\nResp: Resp alkalosis, PO2 67 on 80% aerosol mask and 4lnc. No c/o SOB. Desats to 80% with turning. LCTA decreased bases.\n\nCV: Afib 80-100. Afebrile. ABP 130/80's. Amiodarone gtt. Last ptt 36. Heparin gtt increased to 1000u/hr. Pulses palpable to left lower extremeties. Warm to touch. Rt great toe cyanotic. NTG oint applied. No DP pulse noted to Rt leg.\n\nGI/GU: Abdomen soft, flat. NPO. Bowel sounds present. Foley cath. Clear, yellow urine.\n\nEndoc: RISS\n\nPlan: Wean fio2 as tolerated. Increase activity. Follow abg. Reassess swallow function. ?PPN/TPN. Insert ngt and start tube feed. Monitor ptt.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-11 00:00:00.000", "description": "Report", "row_id": 1510373, "text": "Neuro: pt received intubated, communicated through writing\n\nCV: Afib 90's, IV lopressor 15mg given; t max 100.4, 650 mg tylenol given; SBP 120's, a line correlates with cuff; 1600 PTT 72\n\nResp: on CPAP, 40% FiO2, 8 PEEP, 5 PS; metabolic alkalotic ABG; K & Ca repleted\n\nGI: Abd soft, hypoactive bowel sound, TF impact FS restarted @ 40ml/hr after abdominal US, tube placement checked\n\nGU: Foley draining amber clear urine\n\nInteg: See carevue\n\nEndo: Cover per CSRU protocol\n\nSocial: family in for visit\n\nPlan: trach & PEG tomorrow; NPO after midnight; heparin off after midnight for OR tomorrow; monitor labs, hemodynamics & resp status\n" }, { "category": "Nursing/other", "chartdate": "2174-04-12 00:00:00.000", "description": "Report", "row_id": 1510374, "text": "Resp Care\nPt. remains intubated on PSV with no changes overnight. Vt's 450-550cc with avg MV 10-12lpm.\nBs: ess. clear uppers, dim. at bases.\nabgs:metabolic alkalosis with good oxygenation.\nPlan: Was scheduled for trach, however may not go d/t elevated WBC.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-12 00:00:00.000", "description": "Report", "row_id": 1510375, "text": "7p-7a\nneuro: pt alert, opening eyes spontaneously, MAE with equal strength, follows commands. +PERRL. medicated with tramadolx1 for abd pain with good effect.\n\ncv: remains sr 70-90's without ectopy throughout the shift. lytes repleated . continues amio gtt and ivp lopressor q4hrs. sbp 110-140. heparin off at midnight for ?trach/prg today.\n\nresp: ls clear, dim at bases. see flowsheet for settings and abg's. no changes. ?trach today\n\ngi/gu: abd soft, +bowel sounds, +lrg liquid stool. tube feeds off at modnight. c/o ruq abd pain, resloved after tube feeds stopped and tramadol given, team aware, monitoring amylase/lipase. indwelling cath draining clear yellow urine, diureses with lasix.\n\nendo: RISS\n\nplan: continue to monitor cv/resp. wbc elevated today, questionable trach/peg for today. continue amio gtt, continue metop and all other current meds/antibiotics.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-04-12 00:00:00.000", "description": "Report", "row_id": 1510376, "text": "Respiratory Care: Pt remains orally intubated and vented on PSV. No vent changes done today. Pt had a thoracenthesis this morning without incident. Pt to go to OR for a trache and PEG today. Lung sounds slightly coarse that clear with suctioning. Suctioned for moderate thick white secretions. MDIs given as order. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-12 00:00:00.000", "description": "Report", "row_id": 1510377, "text": "Awaiting or is on call for peg and trach and gallblader removal later\ntoday, heparin and tf's off since mdnight.\n\nNeuro: alert, following commands correctly, mae, denies pain, pupils are equal and reactive to light.\n\nCardiac: nsr no ectopy, continues amio gtt, sbp wnl's, continues 15mg iv lopressor q4 to keep out of a-fib, palpible pedial pulses, skin warm dry and intact, afebrile.\n\nResp: lungs ronchi in upper lobes, dim in bases, sxned for small amounts of thick white, no vent weaning on 5 of ps,8 of peep, 40%o2 and abg's all wnls, taped in left lung for 500cc.\n\nSkin: chest with dsd that is , medialstinal dsd is , right dsd is , coccyx is red but no breakdown.\n\nGi/Gu: npo, abd is soft round and intermittent tenderness to touch, does have good bowel sounds, on riss, making good u/o, did have lasix order d/c'd in am.\n\nSocial: family in to visit and updated via team and nsg.\n\nPlan: npo, continue amio, preop teaching for or.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-04-14 00:00:00.000", "description": "Report", "row_id": 1510382, "text": "Respiratory Care:\n\nPatient trached with 8.0 Portex. Pt. weaned to trach mask yesterday from 9am to 9:45pm. Tolerated well. Patient rested on PSV 5, Peep 5, Fio2 40%. Spont vols 450-500's with RR low 20's. Sx'd for sm white secretions. Trach site oozing with thick bloody secretions around stoma. BS clear bilaterally. Combivent given Q4hr and Flovent .\nRSBI 44 this am. No further changes made.\nPlan: Continue with trach mask trials resting on PSV as needed. Suggest re evalulation of trach.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-16 00:00:00.000", "description": "Report", "row_id": 1510390, "text": "NEURO: alert, ox3, PERRL. following commands, MAE. UE's lift and hold, LE's move on bed. RLE able to lift heel off bed slightly. c/o generalized discomfort at beginning of shift treated with ultram and acetamin. with good relief.\nCV: sinus rhythm, some atrial ectopy noted. SBP 90's-100 tolerating PO lopressor and amio dose. tolerating IV lasix 20 mg with limited diuretic response. cap refill wnl, DP/PT palp. scd's on. cvp 3-10. heparin gtt adjusted as ordered.\nRESP: lungs clear with diminished bases, tolerating trach collar all noc. tolerates speaking valve. removed for noc by resp. sats 93-98%. occasional dry cough.\nGI/GU: abd soft, hyperactive bowel sounds. loose/liq brown BM mult. times overnoc. tubefeeds advanced with no residual. FIB applied. condom cath with amber/clear urine.\nENDO: elevated blood gluc treated with CSRU RISS\nSKIN: sternal incision steristrips , dsd changed, mediastinal chest tube site approximated, , abd staples , G tube site dsd changed. coccyx with red , aloevesta and antifungal cream applied.freq. skin care and repositioning.\nA/P: continue to monitor cv, resp. continue OOB with , blood glucose and lytes, skincare. in process or rehab screening. heparin gtt next PTT due 1100.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-16 00:00:00.000", "description": "Report", "row_id": 1510391, "text": "Respiratory Care\nPt remains on trach collar and Passey-Muir Valve throughout most ofthe shift. Suction times one for scant amount of thick pale tan secreations.\nBreath sounds equal.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-16 00:00:00.000", "description": "Report", "row_id": 1510392, "text": " 7a-7p\nneuro: a+o x3, mae, talks with passy muir valve, perrlaa, normal movement of UE, moderate strength; weak lower extremities, move on bed; up to chair x ~2 hours with use of lift\n\ncv: sr 78-92 no ectopy, sbp 102-120, heparin gtt at 1200 units/hr all day, next ptt at 2300, afeb\n\nresp: lungs cta diminished to bases, on trach collar all day 40% 02 sats >96%, clears secretions to mouth and then suctions with yankauer, trach care with inner cannula change at 1800\n\ngi: hyperactive bowel sounds, tf impact with fiber at 85ml/hr (goal) with residuals <10ml, fingersticks wnl no insulin coverage today, abdomen soft mildly distended, fecal incontinence bag in place draining soft brown stool\n\ngu: condom cath changed x3 (not sticking) draining amber urine, lasix 20 mg iv with good result\n\nlabs: repleted K+/Ca++\n\nassess: stable\n\nplan: continue rehab workup, pulmonary toilet, increase activity, active rom, continue trach collar\n" }, { "category": "Nursing/other", "chartdate": "2174-04-14 00:00:00.000", "description": "Report", "row_id": 1510383, "text": "csru npn\nsee carevue for detailed vs/interventions/assessments.\n\nneuro: alert, mouthing words/using alphabet board to communicate. c/o \"mild\" pain - medicated w/tylenol, good relief. b/l arm movements weak, moves b/l legs on bed only.\n\ncv: afib 100-120s, no vea. amio gtt @ 0.5. b/p stable. d5 1/2ns @ 50cc/hr continuous infusion. given 1 unit rbc for hct 27.1 and oliguria - repeat hct this am 26.\n\nresp: trached. was on 40% trach collar at beginning of shift. rested on cpap 0.40/5/5. secretions not passing thru trach but coming around appliance. self yankaur sxn.\n\ngi: j/g tube clamped. meds down j-tube. hypo bs x 4. jp minimal drainage.\n\ngu: at beginning of shift, huo 5cc. given 1 unit rbc & 500 cc LR bolus. ~ 500 cc out after foley irrigated with ns. amber w/sediment.\n\nendo: ssri\n\nid: tmax 98.8. on iv zosyn, vanco. wbc pending.\n\nplan: trach collar today. ? start tube feeds via j/g tube. aggressive pulmonary toilet. frequent trach care. oob > chair. pain management. monitor hemodynamics.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-14 00:00:00.000", "description": "Report", "row_id": 1510384, "text": "Neuro: alert and oriented x 3, mae, passuy-muir vale placed and communicating appropriatly, following commands correctly, oob to chair with , did active and passive body movements and sat on side of bed, did get one time tylenol for pain.\n\nCardiac: afib then went up on lopressor po and now in nsr, sbp wnl's, amio gtt off started po amio, palpible pedial pulses, skin warm dry and intact, afebrile, skin warm dry and intact, +2 edma in legs, started back on heparin at 800/hr awaiting post ptt results.\n\nResp: on trach mask 40% with sats of 98%, lungs are dim in bases bilat, ? resting on vent at night, also sats are good while on passuy-muir valve.\n\nSkin: chest with dsd that is , medialstinal dsd is , coccyx is red with and no breakdown.\n\nGi/Gu: started tf's today via j-tube, g-tube is clamped, abd is soft round and slightly distended, patient c/o intermittent abd pain with cough and movement, does have + bowel sounds, making around 40/hr u/o, maintance fluid d/c'd today to start tf's, did get supository but no results.\n\nSocial: family in to visit and updated.\n\nPlan: ? vent at night, monitor ptt's, advance tf's toward goal.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-14 00:00:00.000", "description": "Report", "row_id": 1510385, "text": "Patient placed on T-Mask early AM. Passy-Muir valve applied with good result.Patient on Combivent 6-8 puffs and Flovent . Hard to ear via (R) ear,expectorates on commands,may sleep on T-mask without Passy-Muir valve.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-15 00:00:00.000", "description": "Report", "row_id": 1510386, "text": "Resp Care: Pt continues on 40% TM. Pt with good strong non-productive cough. Pt suctioned for small amounts of thick white secretions. PMV in place while pt is awake->pt tolerates well. Flovent given . PLAN: continue on TM\n" }, { "category": "Nursing/other", "chartdate": "2174-04-17 00:00:00.000", "description": "Report", "row_id": 1510393, "text": "Respiratory Care: Pt trached with #8 portex on 40% trach collar. PMV on all night, per pt's request. RN aware. Tolerating well. Flovent MDI given . ? rehab soon.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-19 00:00:00.000", "description": "Report", "row_id": 1510402, "text": "rehab screening continues,discharge summary commenced.oob->chair x 2,tolerated well in chair but unable to weight bear upon return. poor pivot to bed with legs sliding out from beneath him,cont. to c/o numbness lt. leg. attempted again on 2nd oob with p.t. using transfer belt with better success.remains npo pending video swallow tomorrow,see consult.lots liquid loose brown stool. glucoses as recorded,see flow sheet.no resp. issues,strong non productive cough.tolerating p. muir.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-20 00:00:00.000", "description": "Report", "row_id": 1510403, "text": "7P-7A\nNEURO: A/OX3. MAE. PERRLA. Pleasant and cooperative with nursing care. Tolerating P/M valve, removed overnoc. Afebrile. Slept well. PO Tramadol for pain with (+)effect. back to bed from chair, pt unable to stand.\n\nCV: NSR 80-90's no ectopy. Lytes . SBP 90-110's. PO Amio, Metoprolol. Dopplerable pulses R, palpable pulses L. R foot cool to touch. CSL for DVT prophylaxis.\n\nRESP: Trach collar 40%. O2sat >96%. LS cl, coarse at times, diminished bases. MDIs as ordered.\n\nGU/GI: Foley to gravity with adequate HUO. IV Lasix with (+)diuresis. ABD snt (+)BS. FIB in place collecting liquid brown stool. Tolerating Impact fiber TF @ goal 85cc/hr via Jtube. No residual. PPI for GI prophylaxis.\n\nENDO: FSBS coverage per CSRU protocol.\n\n**SEE CAREVUE FOR SKIN ASSESSMENT**\n\nPLAN: Swallow study today. Continue rehab planning.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-04-20 00:00:00.000", "description": "Report", "row_id": 1510404, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with 8.0 Portex DIC trach tube. On 40% trach mask. PMV on with cuff deflated and off before sleep. Good vocalization. Able to cough up secretions. Team in this AM and placed PMV back on.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2174-04-20 00:00:00.000", "description": "Report", "row_id": 1510405, "text": "Nursing 7a-7p\nTraveled to fluoro for video swallow. Slightly orthostatic when placed in chair- sbp 81, asymptomatic, recovered to 110 by end of study.\n\nNeuro: A&Ox3. Needs encouragement to move all extremeties. Did participate actively in ROM this am. This RN noticed great improvement in this pt's helping w/repositions.\nResp: PMV remained in all shift. 40% fio2 via trach collar. Sats 98-100%. Clearing secretions. Lungs w/rhonchi that cleared after coughing in upper lobes. Dim in lower lobes. MDIs per order.\nCV: NSR. No ectopy. SBP stable . PO TID lopressor. PO amio. Lytes wnl. +PP, R leg weaker than L leg.\nGi: Passed video swallow. Advanced to soft diet, thin liquids. Encouraged to swallow an extra time after every bite. TFs cont @ goal. Loose brown stool continues via FIB.\nGu: Adequate HUO. +diuresis from ivp lasix.\nEndo: RISS.\nSkin: See carevue for incisions. Coccyx has a pressure sore.\nSocial: Wife & daughter into visit pt after video swallow. Talked to case management via phone. Updated by RN & NP.\n\nPlan: Increase diet as tol. Encourage independent activity/ROM. Continue rehab screening/planning. Skin care.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-04-17 00:00:00.000", "description": "Report", "row_id": 1510394, "text": "NEURO: alert, ox3, MAE and following commands. UE's lift and hold, weakened. LE's move on bed, able to lift r heel off bed. no pain issues.\nCV: sinus rhythm, SBP 100's-120's. tolerating PO metop and amio. lasix IV with some response. skin warm and dry, DP/PT palp. scd's on.\nRESP: lungs clear with diminished bases, tolerating trach collar all noc. tolerating speaking valve. sats 95-96%.\nGI/GU: tolerating tubefeeds at goal. <5 cc residual. abd soft +bowel sounds brown loose stool draining in FIB. condom cath/penis pouch falling off and inaccurate I&O, so foley cath re-inserted with 1L urine out. amber, clear.\nENDO: blood glucose covered with CSRU RISS\nSKIN: sternal incision with steristrips/mediastinal chest tube site , dsd changed, abd staples and gtube , dsd changed. R thoracotomy with sutures, small amt serous drainage, dsd changed. to coccyx. freq. skincare.\nA/P: continue to monitor cv, resp, on trach collar. tubefeeds at goal, skincare freq. blood gluc and lytes. continue rehab screen.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-17 00:00:00.000", "description": "Report", "row_id": 1510395, "text": " 7a-7p\nneuro: a+o x3, perrlaa, follows commands, moves UE wnl, right LE stronger than left LE, pt c/o numbness to left thigh (team aware), to chair x2 hours with \n\ncv: sr 82-93 no ectopy, sbp 108-128, afeb\n\nresp: lungs cta, diminished to bases, 02 sats 93-97% on trach collar fi02 40%, pt speaking through passey-muir valve without difficulty, pt clearing secretions effectively with coughing, trach care this pm inner cannula changed\n\ngi: positive bowel sounds, tf at 85ml/hr(goal) with residuals <5ml, g-tube clamped, fingersticks ssri, meds and tf to j-tube, fecal incontinence bag in place, c diff sent this am\n\ngu: foley to gravity draining clear yellow urine in large amounts, lasix 20 mg iv x1 this am\n\nlabs: repleted K+, wbc ^ -> c diff sent continuing abx\n\nsocial: family visited x 3 hours this pm\n\nassess: stable\n\nplan: continue abx, continue rehab w/u, continue tf, downsize trach?, replete electrolytes \n" }, { "category": "Nursing/other", "chartdate": "2174-04-17 00:00:00.000", "description": "Report", "row_id": 1510396, "text": " 7a-7p\naddendum: started coumadin po 5mg today\n" }, { "category": "Nursing/other", "chartdate": "2174-04-18 00:00:00.000", "description": "Report", "row_id": 1510397, "text": "Respiratory Care: Pt trached with #8 portex. PMV removed for night, aerosol trach mask in place. Received flovent MDI. Minimal secretions.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-21 00:00:00.000", "description": "Report", "row_id": 1510406, "text": "NEURO: PT IS A&OX3, COOPERATIVE. VERBALIZES NEEDS EFFECTIVE VIA PMV. FOLLOWS COMMANDS. MAES THOUGH SLOWLY, BUT NEEDS ENC. STATES LEFT LEG \"FEELS UNCOMFORTABLE\". ULTRAM GIVEN W/GOOD EFFECT.\n\nSR: SR 70S. NO ECTOPY. BP STABLE, 100S-110S WHILE AWAKE, 90S AT REST. +PP. EXTRS W/D. AFEBRILE. WBC 21.7\n\nRESP: PMV ON INITIALLY, THEN OFF @ HS, TC @ 40%. RESP RATE 10S, SATS >96%. GOOD COUGH, NO SECRETIONS RAISED. MDI'S PER RT.\n\nGI/GU: TF @ GOAL, STR IMPACT W/FIBER VIA J-TUBE, NO RESIDS. PT PASSED VIDEO SWALLOW STUDY PREVOIUS SHIFT, SOFT DIET & THIN LIQS ALLOWED. PT INSTRUCTED TO SWALLOW ONCE EXTRA AFTER SOFT FOODS. +BS. FIB W/SM AMT THIN BROWN STOOL INITIALLY INTACT, BECAME DISLODGED AFTER LARGE STOOL. ADEQUATE HUO, CLR YELLOW, DIURESED WELL FOR 1HR AFTER IVP LASIX. BUN 30, CREATININE 0.7.\n\nENDO: BS PER SS PROTOCOL.\n\nSOCIAL: NO CALLS FROM FAMILY OVERNIGHT.\n\nPLAN: CONTINUE MONITORING CARDIORESP STATUS, LABS. PULM TOILET. INCREASE ACTIVITY & PO INTAKE AS TOLERATED. UPDATE PT/FAMILY RE: STATUS. CONTINUE REHAB PLANNING.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-21 00:00:00.000", "description": "Report", "row_id": 1510407, "text": "RESPIRATORY CARE NOTE\n\nPatient remians on 35% TM this AM. PMV on with cuff deflated. Able to expectorate secretions orally. Vocalizing well with PMV in place.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2174-04-21 00:00:00.000", "description": "Report", "row_id": 1510408, "text": "NEURO: PT. ALERT, ORIENT X3, EXTREMELY PLEASANT MAN, MAE-> LIFTS AND HOLDS BOTH UPPER EXTREMITIES, LOWER RIGHT EXTREMITY, MOVES LEFT LOWER EXTREMITY ON BED (EXTREME WEAKNESS), OBEYS COMMANDS.\n\nCV: PT. NSR, HR 80-90'S, SBP >90, MAP >60, NO ECTOPY NOTED. LOPRESSOR PO ORDER HELD TODAY AT 1200 DUE TO SBP IN LOW 90'S- AMIODARONE 400MG PO GIVEN AND TOLERATED.\n\nRESP: PT. LUNG SOUNDS CLEAR IN UPPER LOBES, CLEAR IN RIGHT LOWER LOBE AND DIMINISHED IN LEFT LOWER LOBE. PT. ON TRACH MASK ON 35% FIO2- PASSY-MUIR VALVE IN PLACE, PT. PASSED SWALLOW EVAL YESTERDAY- SPEECH/SWALLOW IN TO SEE PATIENT TODAY- + NONPRODUCTIVE COUGH. OXYGENATION REMAINS >95%.\n\nGI/GU/ENDO: ABD SOFT, +BS, PT. C/O LEFT LOWER QUADRANT NP AWARE. +FLATUS, PT. TAKING IN SOFT FOODS AND LIQUIDS AND TOLERATED. NUTRITION ORDER CHANGED FROM CONTINUOUS TUBE FEEDS TO PO INTAKE DURING THE DAY AND TUBE FEEDS (IMPACT WITH FIBER 3/4 STRENGTH) FROM 1900-0700 VIA J-TUBE. FOLEY DRAINING CLEAR, YELLOW URINE, BLOOD SUGARS TREATED PER RISS.\n\nPAIN: ULTRAM GIVEN ONCE FOR PAIN AND RELIEF FOUND PER PT.\n\nPLAN: REHAB SCREENING TOMORROW? (), MONITOR PULMONARY STATUS, REST PT. RESPIRATORY WISE (REMOVING PASSY-MUIR VALVE) OVERNOC, ADVANCE PT AND OT CONSULTS.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-03 00:00:00.000", "description": "Report", "row_id": 1510349, "text": "NEURO: lethargic, arouses to voice and oriented to , with cueing. mumbling and at times difficult to understand but content of conversation seems lightly more appropriate than friday noc . MAE on bed. passive ROM done.\nCV: a fib rate mostly 90's. sbp 110's-130's. tolerating lopressor, vasotec, lasix IV. good diuretic response. + generalized edema. DP/PT palp. heparin gtt sub therapeutic, increased to 1700 will recheck PTT 0600.\nRESP: lungs with crackles at R base, diminished L base. chest tube L pleural with serosang drainage, large amounts with turns in bed. R chest tube site with small amount serosang drainage, bag intact. meds given crushed in applesauce per S&S eval. reccomendations, but ?pt aspirating. increased swallowing, throat clearing noted after medication. pt with non-productive cough, cough effort seems decreased.\nGI/GU: abd soft, +bowel sounds. had small liq BM. foley with yellow urine, good diuresis.\nENDO: blood glucose not requiring RISS.\nSKIN: on back/coccyx treated with aloevesta/antifungal cream. sternal incision, chest tubes, L thoracotomy dsd changed. no drainage, no erythema.\nSOCIAL: no calls this shift.\nA/P: continue to monitor cv, resp, blood glucose and lytes, skin care, ROM. monitor mental status and re-orient OOB to chair with . needs NGT and cordis change to 3 lumen.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-03 00:00:00.000", "description": "Report", "row_id": 1510350, "text": "7A-7P\nNUERO: Alert. Oriented to self and year, @ times to place. PERRLA. Confused/mumbling speech continues. MAE. Consistently follows commands. Afebrile. OOB to chair. Family visit today.\n\nCV: Afib 70-90's. No ectopy noted. Lytes repleted . SBP 90-130's. IV Metoprolol and IV Vasotec continue. Palpable pulses bilat. LE cool to touch bilat. CSL for DVT prophylaxis. Heparin GTT continues as ordered. NEXT PTT due @ 2300.\n\nRESP: LS crackles R base, diminished L base. (+)Cough. O2sat >95% 50% face tent. CT to 20cm suction with moderate amount S/S drainage. No airleak. Collection bag to R chest tube site with no drainage.\n\nGU/GI: Foley to gravity with good HUO. IV Lasix (+)diuresis. ABD snt (+)BS. Brown liquid BM x1 today sent for CDIFF.\n\nENDO: FSBS per CSRU protocol.\n\nSEE CAREVUE FOR SKIN ASSESSMENT.\n\nID: IV Zosyn continues. IV Vanco restarted .\n\nPLAN: Monitor CV/RESP status. Continue Heparin GTT next PTT @ 2300. Pulmonary toileting. Change cordis to triple lumen. ? Dophoff placement.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-06 00:00:00.000", "description": "Report", "row_id": 1510356, "text": "See and carevue for detailed documentation\n\nNeuro: Patient alert, oriented x2-3. Slow to remember hospital name, date. Sometimes requires reminding. Patient with c/o of L hip/ LLQ pain. Slight relief with repositioning. Worked with PT, OOB with maximal assist. Anxious thru day. Worried about prostate cancer return, asking what the options are for inoperable cancer. Asking for if his wife has \"operable power of attorney\". state that he \"can't go thru another night, I want to sign the DNR\" Clamer thru dat with reassurance. Start on tramadol with some improvement in c/o pain. Difficult to assess pain per pain scale. patient not using number scale appropriately. Calmer and less anxious with family at bedside.\n\nResp: Patient on RA for most of day. Tolerated well with SAT >(#%. BS clear, diminished in bases. In afternoon patient with c/o SOB with anxiety. NC 4L with improvemnt.\n\nCV: In NSR HR 80's. PAC's in am ->resolved. BP 90-140/50-60. Aline dampened. HCt stable. Heparin gtt off, coumadin on hold. Peripheral pulses palpable, R side weaker that L, cooler.\n\nGI: Took baricat, tol well. Moderate loose brown stool on bedpan.\nTook small amount po thru day.\n\nEndo: RSSI per protocol. No coverage needed.\n\nGU: Foley to gravity with small amounts clear yellow urine.\n\nSocial: Family at bedside. Supprotive of patient.\n\nPlan: Continue cardiopulmonary monitoring. Follow serial Hcts as ordered. manage pain with po meds, repositioning. ? transfer to 2 if Hct stable.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-06 00:00:00.000", "description": "Report", "row_id": 1510357, "text": "Patient with decreased BP 90/50's. Rec'd 250ml NS bolus with slight imptovement. Hct before bolus 21. Type and screen sent. Ordered for 2Units PRBC. 18G PIV placed.\nPlan: Follow HCt, if does not bump appropriately consider FFP per team.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-07 00:00:00.000", "description": "Report", "row_id": 1510358, "text": "7P-7A\n****PT TO O.R. @ 0500 for REPAIR OF ? RETRO-PERITONEAL BLEED******\n\nNEURO: Alert. Oriented to self, year, & at times to place. Making confused statements. PERRLA. and cooperative. Consistently follows commands. C/o LLQ aching. Per Pt pain much improved from yesturday. Temp as low as 92.5 orally, bair hugger in place with (+)effect. Pt wife updated on by MD .\n\nCV: ST 100-110's. No ectopy noted. Lytes . Hypotensive to 70's Levophed GTT started to maintain MAP >70. HCT 19.6. 4 units PRBCs administered. Post HCT @ 0000 28.5, 3 units FFPs administered. NS fluid bolus total 2.5 liters. HCT @ 0300 20.7. PO Vit K administered. Extremities cool to touch. Pt pale. Palpable pulses bilat. CSL for DVT prophylaxis.\n\nRESP: LS clear dim @ bases. ABGs alkalotic. RR 20-30s. 4L NC O2sat >95%. MDIs as ordered.\n\nGU/GI: Foley to gravity with amber colored minimal UO. CR elevated to 1.6. Mucomyst PO BID. ABD snt (+)BS. Scant amount loose/liquid brown stool. PPI for GI prophylaxis.\n\nENDO: FSBS per CSRU Protocol.\n\nSEE CAREVUE FOR SKIN ASSESSMENT.\n\nPLAN: Continue to monitor BP, HCT, GU & RESP status.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-09 00:00:00.000", "description": "Report", "row_id": 1510364, "text": "NEURO: Confused and delusional since this afternoon, Pt states \"hears wife (when not present) and a person on the end of the oxygen tube,\" Pt reoriented, denies any pain\n\nRESP: Weaned O2 to 6L NC, Sats 94%, ABG shows resp alkalosis with PaO2 of 58 on 4L NC, increased O2 to 6L, lung sounds clear at apices, dim/crackles at bases, cough is weak (difficult to get sputum sample), ?plan to reintubate tonight/trach&PEG Monday\n\nCV: Afib with HR in 70-80s, continues on 1mg Amio drip, SBP in 110s, a-line is dampened/still draws back blood, plan to rewire, R pedal pulse found by Doppler, R lower leg remains cool/dusky, Vascular is following and plan to continue heparin drip (1200units/hr), please check PTT at \n\nGI/GU: NPO, aspirating PO yesterday, held PO meds, ?plan to insert Dobhoff, BS present, no BM today; Foley in place draining yellow/sediment urine, given Lasix with good response, repleted K/Ca\n\nENDO: Continues on SSRI\n\nID: WBC was 26, max T 99.0, current T 98.2, pan cultured blood x3, urine, unable to retrieve sputum, restarted Pt on Vanco/Zosyn\n\nSOCIAL: Pt visited and updated on Pt status. They feel nervous about the condition of loved one. Consent over the phone for trach/PEG\n\nPLAN: Reintubate tonight, ?Bronch tomorrow, Trach/PEG Monday, continue to monitor neuro, resp, cv, urine output, LABS, replete lytes\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-04-10 00:00:00.000", "description": "Report", "row_id": 1510365, "text": "Nursing Progress Note\nResp: Reintubated at , last eve. For airway protection and secretion management, also \"white out\" chest xray per team. Uneventful, 7.5 ett, 24 cm at teeth, ventilating more effectively. Sats 100 on 0.5, suction for large thick yellow to blood tinged, and copious oral pooling at back of throat. Lungs are coarse in upper lobes and dim at the bases. CXR confirmed proper placement. No bronch at this time.\n\nCVS: with reintubation pt SBP fell rapidly from 140's to 70's. BP support with neo currently at 1.5 mcg/kg/ to keep sbp >100. Art line in r radial significantly dampened, but able to draw labs. Team will change on day shift. Following on left arm. RIJ multi lumen patent x 3 ports. Also receiving Heparin at 1400 units hr, ptt pending. Amiodarone at 1 mg/ and propofol at 10 mcg/kg/ for sedation, reduction of bronchospasm.\n RLE: right great toe dusky and right foot cool, warmer ankle and above. Both pedal pulses now weak palpable. NTG paste applied above right great toe.\n\nSkin: excoriation to buttocks, yeasty, miconazole applied. DSD to intact steri strips on sternum, mediastinal old ct sites approx, with eschar and erythema. Right thoracotomy site approximated but draining sang when cleaned and serosang in large amounts within 2 hours after dressing change.\n\nNeuro: opens eyes to stimulation. Falls back to sleep. Moves to stimulation, x 4 ext. No command following at this time. Gag and cough intact. Perla 3 brisk.\n\nRestraints: bilat UE per med policy to protect ett and lines.\n\nEndo: fs bs covered x 1 with ssri.\n\nGI: abd soft non tender, ogt patent. Placement confirmed on cxray. TF impact at 10 cc hour.\n\nGU: Foley cath with pale yellow urine, large amounts of crytaline sediment. Flushed for low uop last eve, returned large amounts of sediment and 1000 cc of urine, brisk output continued since that time.\n\nSocial: wife called x 1 for update.\n\nPain: no apparent\n\nPlan: continue to monitor, pulmo hygiene, ? bronch. Trach and PEG on Monday. Will need PT.\n\nSee carevue flowsheet and mars for further details and values.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-04-10 00:00:00.000", "description": "Report", "row_id": 1510366, "text": "Respiratory Care Note:\n\nPt was re-intubated @ beginning of shift for airway protection & remain orally intubated & sedated. The intubation was uneventful. BS are dim claer to coarse. RSBI done ~44. We are sxtn for large to cop amt of thick yellowish to blood tinged at times, some cnsiderable orally thick white. Plan: keep intubated, ? trach Monday & Continue present ICU monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-10 00:00:00.000", "description": "Report", "row_id": 1510367, "text": "Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowsheet. Pt changed to SIMV and then to PSV of 5 peep 8 and 40%. TV 500 range RR low 20's. Good ABG's on present settings. Pt awake and alert. MDI's as ordered. Sxn for small amount white, sample sent. Cont current settings, plan is for trache.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-10 00:00:00.000", "description": "Report", "row_id": 1510368, "text": "TRACH/PEG tomorrow\nNEURO: Alert, follows commands, commnunicates non-verbally, denies any pain, MAE, cough/gag intact\n\nRESP: CPAP 40%, PEEP 8, PS 5, lung sounds clear at apices/dim at bases, ABG shows resp alkalosis, copious oral secretions suctioned, plan for bronch & trach/peg tomorrow night\n\nCV: Afib with HR in 80-90s, on 0.5mg Amio, SBP in 90-110s on 0.5mcg Neo, a-line dampened at times and redness noted at site, ?plan to insert new a-line, heparin drip to 1100units/hr, last PTT 116, plan to retake PTT at 1900, pedal pulses palpable, lower EXTs warm/dry, Pt c/o no feeling on L upper leg, transfused 1PRBC\n\nGI/GU: OGT on Impact TF at goal 40cc/hr per with minimal residuals, abd soft, bs present, no BM; Foley in place draining yellow clear urine, overdiuresis with Lasix, repleted K/Ca as needed\n\nENDO: On SSRI\n\nSOCIAL: Wife/son visited Pt and updated on Pt status and plan of care.\n\nID: On Zosyn/Vanco, WBC remains unchanged at 26, afebrile, sputum culture sent today, blood cultures still pending\n\nPLAN: Trach/PEG tomorrow night, continue to monitor neuro, resp, cv, urine output, labs, replete lytes as needed, continue TF\n" }, { "category": "Nursing/other", "chartdate": "2174-04-13 00:00:00.000", "description": "Report", "row_id": 1510378, "text": "7p-7a\nneuro: pt from OR at , report received from anesthesia; anesthesia reversed prior to arival to csru. pt sedated on fent and midaz, no gtts. awakened within 1.5 hrs, opens eyes spontaneously, MAE with equal strength, follows commands, mouthing words/full sentences; answering yes/no questions appropriately. heparin gtt off per team.\n\ncv: remains sr through the night; unable to get a good waveform on the a-line, team aware, going by 's 100-120. continuing metop 15mg iv5 q4hrs, tolerating well. continuing amio gtt. right lower extremity toes feel cooler than the left, dorsalis pedal and tibial lateral pulses are dopplerable (the left lower extremity pulses are easily palpable); vascular team is following pt for this and is aware. received 1unit prbc.\n\nresp: ls clear bilat, inhaler given by resp as scheduled. initially on simv, to cpap when awakened, see flowsheet for vent settings and abg's. o2sats>98. trached last night, #8portex. trach care done, oozy at the site of the trach, team aware.\n\ngi/gu: open chole done, jp draining sm amts serosanguinous. peg placed. g-tube to garvity, draining green color gastric drainage; j-tube clamped. remains npo. indwelling cath draining amber color urine, sufficient amts.\n\nendo: RISS\n\nplan: continue to monitor. ? trach collor today.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-13 00:00:00.000", "description": "Report", "row_id": 1510379, "text": "Respiratory Care:\nPatient returned from OR S/P trach & Peg and cholecystectomy. Placed on SIMV and weaned to previous settings of CPAP/PSV, 40%, . Latest abg results determined a compensated respiratory acidemia with very good oxygenation on the current settings.\n\nRSBI = 48.1 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-13 00:00:00.000", "description": "Report", "row_id": 1510380, "text": "0700-1900:\nneuro: alert, mouthing words and using communication board appropriately. perrl. morphine pain for incisional discomfort.\n\ncv: sr 80-90, no ectopy. remains on amiodarone gtt at 0.5 mg/. electrolytes wnl. right le cool to touch, dopplerable pulses. lle with dopplerable pulses. unchanged per prior assessment.\n\nresp: lungs clear, diminished at times. placed on 40% trach collar with o2 sat 99%. minimal secretions. trach care done. oob-chair.\n\ngi/gu: abd soft, nd. bs absent. j/g tube clamped. tol meds via tube. ? tube feeding in am. foley to gravity, low uo. treated with volume np . cr wnl.\n\nendo: fs qid, cover per riss.\n\nplan: monitor respiratory status. oob-chair.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-13 00:00:00.000", "description": "Report", "row_id": 1510381, "text": "Respiratory Care: Pt recieved trached and vented on PS. PEEP weaned from 8 to 5, Follow up ABG showed acid-base within normal parameters and good oxygenation. Pt placed on trache collar on 40% FiO2 cool aerosol, Pt on trache collar since 9 am tolerating well. Lung sounds slightly coarse that clear with suctioning. Suctioned for small thick yellow secretions. MDIs given via spacer.Plan is to rest pt on vent over noc, and do trach trial again in the am.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-25 00:00:00.000", "description": "Report", "row_id": 1510314, "text": "Admission Note:\n\nSeen by PCP beginning of month w/ c/o not feeling well x's 1 week., unable to get labs drawn. Went to ED that evening w/ c/o N/V, and not feeling well. Found to be in rapid AF rates up to 150's, febrile, UTI/Urosepsis, and pneumonia. Admitted then to OSH and shortly after intubated d/t resp compromise. Negative blood cultures.\n\nRemained in Rapid AF for several days. Developed ARDS requiring high levels of peep, up to 15. PIPs 37. Sats 80-100%. Proned helped saturations. Hypotension on neo (weaned off this afternoon), levo, pit for bp mngt. TEE showed posterior leaflet of MV flopping. Transfered to and taken right to Cardiac Cath Lab.\n\nCardiac Cath = RA 22, RV 71/16, PA 77/42 (54). Wedge 37. Coronary vessels w/o disease. IABP and Femoral swan place in cathlab.\n\nReceived from Cath lab via bed. Connected to bed side monitors and initial assessment completed as noted in care vue flow record. On midaz at 10mg/hr, Levo at .14 mcq/kg/min, and vasopressin at 9.6 units/hr.\n\nROS:\n\nNeuro: Sedated on midaz gtt titrated down to 5 mg/hr. Cisatracurium gtt started after bolus given. Fentanyl 50 mcg given ivp prior to cardioversion.\n\nCV: A fib 110-120. Has left radial ABP line, left femoral Triple lumen, distal lumen clotted off (these lines place at OSH). Has right femoral IABP and Swan. See flow record for hemodynamic details. IABP w/ good augmentation and little unloading. Peripheral pulses dopplerable except for left PT. Vasopressin weaned to 4.6 u/hr. Levo remains on at 0.14 mcg/kg/min. Cardioversion x's 3 shocks w/o return to SR.\n\nResp: Orally intubated an on vent. Lungs clear to auscultation. Sx for thin bloody secreations via ETT. Bilateral chest tubes placed w/2700cc of clear straw colored fluid drained immediatly from each. pO2 improved extensively post CT placement as did ABP and CXR. No resp distress noted, = rise and fall of chest.\n\nGI: sump via nare draining old dark bloody drng. Abd soft w/o bowel sounds. Invol of large liq stool.\n\nGU: Foley patent draining clear amb urine. Lasix 40 ivp at 2200.\n\nLytes/heme: WNL\n\nSocial: Family waiting in family waiting room\n\nPlan: Wean FIO2 as able. Titrate press. agents as necessary to maintain SBP 90-100's. Start fentanyl and heparin gtts. Pulmonary toileting, mobilize. Monitor, tx, support, and comfort. OR on ?? Monday.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-25 00:00:00.000", "description": "Report", "row_id": 1510315, "text": "RESP CARE: Pt recieved from Cath lab intubated/sedated/on vent SEE CAREVUE. Paralytic given. Multiple vent changes made throughout the shift. Following bilat CT insertion Pa02 dramaticall y improved, FI02/PEEP weaned. Lungs dim bilat. Sxd small amts bloody secretions. Last ABG reveals normal ventilation/oxygenation. Pa02 190s on .50/12 PEEP. No RSBI this am due to high PEEP level Wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-26 00:00:00.000", "description": "Report", "row_id": 1510320, "text": "RESP CARE: Pt remains intubated/on vent settings per carevue. No changes this shift. Lungs sl coarse. Sxd bld tinged sputum. ABGs WNL. No RSBI due PEEP level per weaning protocol. Continue full support.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-26 00:00:00.000", "description": "Report", "row_id": 1510321, "text": "resp care\npt changed from ac mode to psv/cpap, tolerating well at ps 10/peep 10/40%. abg within acceptable range. appears comfortable on settings. no further weaning done due to planned o.r. procedure.sxning small amts thick bldy sputum.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-26 00:00:00.000", "description": "Report", "row_id": 1510322, "text": "ROS:\n\nNeuro: Midaz and fentanyl off @ 0800. Facial grimicing and slight attempts to withdraw to nailbed presure. Bites down w/sx ETT and po cares. Early on opened eyes slightly w/cares. No eye opening noted this afternoon. Strong cough and gag. PERRLA.\n\nCV: SR until ~ 1515 when converted to AFib 100-120 VSS. Levo on at 0.08 mcg/kg/min titrated to SBP 90-100.not requiring titration. Vasopressin on at 2.4 units/hr w/o titration. Left radial ABP line dc'd d/t dampend waveforms and unable to draw from line. Has left femoral triple lumen central line. Has right femoral IABP 1:1 w/good augmentation and unloading. Also has left femoral SWAN, w/CO > 5 and CI > 2. Heparin gtt 700 U/hr, PTT 68, notified no new orders. P boots on for DVT prophylaxis. Peripheral pulses dopplerable in LE. All extrem Warm and dry.\n\nResp: Remains oraly intubated and on vent. Weaned to CPAP , 40% w/good ABGs. Lungs clear. Sx thick bloody secreations via ETT. Has bilateral chest tubes to 20 cm sx draining straw colored fluid in large amts. NO resp distress noted, = rise and fall of chest. Sats 95% or >.\n\nGI: Abd soft w/o bowelsounds. Salemsump via right nare. Impact TF stated this AM infused at 20cc/hr untill 1600 when Residual checked and = >150cc. TF stopped, notified and reglan ordered. NG connected to LCS Now starting to drain scant amt of bloody drng.\n\nGU: Foley patent draining clear yellow urine in QS.\n\nEndo: FSG covered this w/RSSI sq.\n\nLytes: K repleted x's 1 this afternoon.\n\nCoag: INR 1.8 Vit K 10 mg given sq x's 3 days.\n\nSocial: Wife and daughter in this afternoon, very supportive.\n\nPlan: Place back on vent support if necessary for the noc to rest if seems to become tired. Pulmonary toileting. Draw CBC and Coags Now. Send new clot to Blood Bank after tomorrow as current clot expires . Check Vanco level prior to dose this evening. Mobilize. Resume fentanyl if seems uncomfortable and sedation if absolutly necessary. IABP 1:1. Monitor, tx, support, and comfort. OR Monday.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-27 00:00:00.000", "description": "Report", "row_id": 1510323, "text": "Respiratory Care: Pt remained on PSV most of night, though did have to go on AC mode for about 3 hours after turning and suctioning. Presently back on PSV 10/10p and tolerating well. No RSBI measured due to ^ peep level.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-15 00:00:00.000", "description": "Report", "row_id": 1510387, "text": " 7p-7a\nneuro: a+o x3, upper extremities weak, but lift and hold. le weak move on bed only. perrlaa\n\ncv: sr 90-96-> afib rate 120-140 given 150mg amio bolus & 5 mg iv lopressor x2-> sr 82-92 no ectopy, 50 mg po lopressor q6 scheduled, amio 400mg po bid scheduled; sbp 106-127, afebrile, heparin gtt at 1100 ptt 45 next ptt due at 0800\n\nresp: trach collar overnight, no suctionning required by rn, lungs cta diminished to bases, 02 sats 96-100%, pt talking with passy-muir valve on cuff down\n\ngi: pt c/o no bm x 3 weeks/abdomen fullness, abdomen soft/distended with bowel sounds wnl, kub->ileus -> tube feed stopped, j tube clamped, g tube draining to gravity, reglan 10 mg iv q6hours, dulcolax suppository-> passed mucous plug, then 2 medium/large liquid stools, pt requesting fecal incontinence pouch this am, currently wearing diaper, no insulin needed overnight\n\ngu: foley to gravity draining 40-70ml/hr amber urine with sediment\n\nlabs: repleted K+\n\nassess: stable\n\nplan: keep on trach collar as tolerated, increase activity, to rehab next week, rectal pouch, replete electrolytes, reglan 10 mg iv q6hours continuous, passy-muir valve to speak, hold tube feeds\n" }, { "category": "Nursing/other", "chartdate": "2174-04-15 00:00:00.000", "description": "Report", "row_id": 1510388, "text": "Neuro: alert and oriented x 3, mae, following commands correctly, no c/o pain, oob to chair with lift.\n\nCardiac: nsr no ectopy, sbp wnl's, palpible pedial pulses skin warm dry and intact, afebrile, +2 edema in legs, continues heparin gtt.\n\nResp: lungs are clear and dim in bases, on trach mask at 40% fio2, tolerated passuiy-miur valve all day with no problems.\n\nSkin: chest with dsd that is , medialstinal dsd is , coccyx is red with no breakdown doublebond cream and nystatin applied.\n\nSocial: family visited and updated.\n\nGi/Gu: npo, restarted t/f's today, hyperactive bowel sounds, on riss, abd slightly distended with intermittent c/o pain, foley d/c'd at 10am and ? patient was incontinent of urine with large liquid bm, condom cath placed and has had 50cc u/o void in condom cath, large amounts over a liter of liquid stools from morning bowel regiment.\n\nPlan: monitor for more u/o in condom cath, hold bowel regiment, increase tf's towards goal.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-16 00:00:00.000", "description": "Report", "row_id": 1510389, "text": "Resp Care: Pt trached with 8.0 Portex. Cuff deflated. Pt tolerates PMV well during the day-> removed at NOC. Pt with strong dry cough. Pt did not require suction. Flovent given as ordered. Plan: continue routine trach care. ? rehab next week.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-27 00:00:00.000", "description": "Report", "row_id": 1510324, "text": "neuro-sedation off for 24hrs.pt unresponsive to voice, but bites down on Ett with sxning or oral care. gently moves head side to side. perla 3mm.\n\ncv-continues in afib rate 112-118. levophed for bp,keep 100-120.hr & rr. increased with stimuli. md notified. 1x dose of fentanyl/versed with no effect. dose repeated,still no effect. md notifed again ordered lopressor 5mg x1. hr decreased to 80-85. rr=25. co/ci stable. IABP 1:1 with good augementation.skin warm/dry. left arm seeping serous fluid. + pp. generalized body edema.\n\nresp- cpap/ps -> imv when tachypneic after complete am care. placed back on cpap/ps this am. +gag/+cough. sxing thick blood tinged-> white secretions via ett. copious amounts thick oral secretions.Ct cont. to drain straw colored fluid.\n\ngi- abd soft. absent bs. tube feed re-started @ 10cc/hr. residual checked 4 hrs later. ogt with thick tube feed in it. flushed with 60cc ns and put to wall sx for 200cc tubefeed-> bilious drg.\n\ngu- adequate amounts yellow urine with bloody speck of sediment.\n\nlabs- K+ repleted x1. glucose =108.\n\npain- no objective signs of pain.\n\nplan- monitor hemodynamics. rate control afib. wean levo to keep sbp 100-120. continue on cpap/ps.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-03-27 00:00:00.000", "description": "Report", "row_id": 1510325, "text": "Neuro: Pt grimaces and opens eyes to painful stimuli. Moving head back and forth on bed, witnessed all extrem move but not to command. Pupils pinpoint but reactive. All reflexes intact. Neuro consulted, awaiting recommendations. ? Ct scan\nCv: Afib, 90-130, rare pvc noted. Titrating Levo to maintain SBP>95, MAP >60, vasopressin 2.4 units/hr. NS IVF 500cc for rising pressor requirement. Grossly edematous. Palp pedal pulses. PAD 20's, CVP <10. Heparin decreased to 600 units/hr for PTT 70, repeat pending.\nResp: Cont on CPAP Fio2 40%. Sx thick blood tinged. PO2>100, sats>98%. lungs coarse throughout. IABP 1:1, good augmentation. CI>3.\nGI: TF on hold due to lg residuals overnight, abd soft. hypoactive bs. No BM\nGu: uop marginal, sediment urine, concentrated urine\nEndo: BS covered by ssr. see flowsheet\nID: TMAX<100, ID following. Flagyl dc'd , vanco increased.\nSocial: Wife at bedside. Very critical of care at , emotional support given\nPLan: Awaiting neuro consult recommendations. Cont assess cardio/resp status. Titrate levo as tolerated. ? OR in am if stable.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-27 00:00:00.000", "description": "Report", "row_id": 1510326, "text": "resp care\nremains intubated/vented in psv/cpap, no further weaning attempted today. rr mid 20's, Ve low to mid teens. sxned for small amts thick bld tinged sputum. awaiting o.r.procedure.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-18 00:00:00.000", "description": "Report", "row_id": 1510398, "text": "NEURO: alert, ox3, good amount of sleep overnoc. MAE, UE's lift and hold, RLE lift/fall LLE moves on bed. following commands. c/o generalized aches, medicated with acetamin. po with good result.\nCV: sinus rhythm, sbp 100's-130. tolerating po lopressor and amio doses, good rate control. lasix IV with good diuresis. skin warm and dry, DP/PT palp.\nRESP: lungs clear with diminished bases, tolerating trach collar overnoc, nagging cough with humidified 02, minimally productive. suctioned x1 for scant secretions, expectorating tan secretions. sats 95-98%. tolerating speaking valve, reapplied this AM.\nGI/GU: abd soft, +bowel sounds. tolerating tubefeeds at goal with <5cc residual. loose brown stool draining in FIB. foley with large amts. yellow urine clear-->cloudy.\nENDO: blood glucose elevated treated with CSRU RISS\nSKIN: to coccyx, aloevesta applied. sternal incision steristrips , mediastinum approximated, , abd staples , J tube site , r thoracotomy sutures . dsd applied.\nA/P: continue to monitor cv, resp, continue trach collar and PM valve, OOB with lift, blood gluc. and lytes. follow wbc, send cdiff #2 today.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-18 00:00:00.000", "description": "Report", "row_id": 1510399, "text": "0700-1900:\nneuro: alert and oriented x 3, mae. perrl. wearing speaking valve, awaiting swallow eval to resume po. denies pain.\n\ncv: sr 80-90, no ectopy. sbp remains 100-110. electrolytes repleted per orders. remains on lopressor 50 mg po tid. heparin gtt at 1200 units per hour, ptt 74. coumadin 5 mg po given. easily palpable pedal pulses bilaterally. right foot cooler to touch, team aware.\n\nresp: lungs clear, diminished bilateral bases. o2 sat 94-98% on 40% trach mask. productive cough.\n\ngi/gu: abd softly distended. bs positive. tube feeding at goal, no residuals. ct scan of abdomen and pelvis done. foley to gravity, good huo. lasix .\n\nendo: fs qid, cover per riss.\n\nid: wbc elevated, vancomycin and piperacillin tazobactam d/c'd. po flagyl started. initial c diff negative.\n\nplan: rehab screen, monitor wbc, await c diff results.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-19 00:00:00.000", "description": "Report", "row_id": 1510400, "text": "RESPIRATORY CARE:\n\nFollowing pt for trache care protocol. PMV removed for pt to sleep. Neb filled. No sx required, pt Equipment in place. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-19 00:00:00.000", "description": "Report", "row_id": 1510401, "text": "7P-7A\nNUERO: A/OX3. MAE. PERRLA. Pleasant and cooperative with nursing care. Tolerating P/M valve, removed overnoc. Afebrile. Slept well. No c/o pain.\n\nCV: NSR 80-90's no ectopy. Lytes . SBP 100-110's. PO Metoprolol and Amio. Heparin GTT @ 1100units/hr. Dopplerable pulses on R, palpable pulses on L. R foot cool to touch. CSL for DVT prophylaxis.\n\nRESP: 40% trach collar. LS cl dim at bases. O2sat >95%. MDIs as ordered. EXP thick yellow sputum. Suctioned x1 for scant tan sputum.\n\nGU/GI: Foley to gravity with adequate HUO. IV Lasix with (+)diuresis. ABD snt (+)BS. Tolerating TF Impact Fiber 3/4 strength at goal 85cc/hr via Jtube. No residual. FIB in place collecting liquid brown stool.\n\n***SEE CAREVUE FOR SKIN ASSESSMENT***\n\nENDO: FSBS coverage per CSRU protocol.\n\nPLAN: Continue Heparin GTT, next PTT due @ 1000. Monitor WBC continue PO Flagyl. Pulmonary toileting. Continue TF @ goal ? swallow eval.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-29 00:00:00.000", "description": "Report", "row_id": 1510334, "text": "shift update:\n\nor on hold d/t wbc 27 & temp spike overnight family in and aware. ?or in am. unsure if wife aware of potential for or in am will check with team.\n\nneuro: sedated on propofol. pearl. spontaneous movements noted in bilat legs on bed. no movement noted in arms. appears comfortable but does grimaces w/mouth care/turning. t&r x2, did not tolerate side postion returned to back.\n\ncv/skin: afib w/hr initially 100-110 then 70-90's after lopressor. cont on vasopressin. required increase in levo to maintain map>60 sbp>90, unable to wean levo. lopressor d/c'd & plan to wean lev as tol per cardiology. iabp weaned to 1:2 but increased back to 1:1 after drop in svo2, co & bp. currently svo2 low 60's, ci>2 & sbp>90. heparin restarted & increased to 800u/hr at 1600 ptt due at 2200. bilat ct draining mod amt straw colored fluid, cx sent from both ct's. ca & k+ repleted. +palp pp bilat. skin intact. coccyx pink.\n\nresp: lungs clear but dim in bases. abg's metablolic alkalosis team aware. periods of apnea noted, team aware. vent changed to mmv 50% 600x12 ps 15 peep 10. abg's unchanged. suctioned for thick bloody secreations. sputum cx sent.\n\ngi/gu: ntg +placement, tf restarted. npo after mn for ?or. ducolax supp given w/o effect. needs stool for cdiff. uop adequate. ucx sent.\n\nid: tmax99.3. ivabx changed to zosyn, gentamycin & vanco.\n\nendo: fs treated w/ssri per protocol.\n\nsocial: family into visit this am. update given.\n\nplan: npo & stop heparin at mn for ?or in am. wean levo as tolerates. cont to monitor hemodynamics, resp status, labs, i&o. gent level in am.\n" }, { "category": "Nursing/other", "chartdate": "2174-03-30 00:00:00.000", "description": "Report", "row_id": 1510335, "text": "Respiratory Care\nPt remains intubated with 7.5 ETT. Pt currently on MMV mode of ventilation. No vent changes made this shift. BS coarse bilaterally and diminished at lung bases. Suctioning for moderate amounts of thick bloody secretions. ABG shows partially compensated metabolic alkalosis. No RSBI completed (PEEP>10). See CareVue for details and specifics.\nPlan: Wean as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2174-03-30 00:00:00.000", "description": "Report", "row_id": 1510336, "text": "Nursing Progress Note:\nNeuro: Propofol gtt. Attempted to wake up pt but SVO2 decreased to 50's with propofol off for few minutes. However, pt MAE and opened eyes spontaneously. Gag and cough intact. Perl 2mm brisk.\n\nResp: LCTA decreased at bases. Sats 99% on MMV 600, RR 12, peep 10, ps15, 50% Suctioned for small amount of thick, blood-tinged secretions. B/L pleural CT to 20cm wall suction, Draining moderate amount of straw fluid. No air leak or crepitus noted. Metabolic acidosis unchanged.\n\nCV: Afib. HR 80-100's. SBP goal >90 and map goal >65. Pt on vasopressin gtt. Unable to wean levophed. HCT down this am to 26. SVO2 >60 (decrease when attempted to wake up pt), CI >2. Tmax 100.2. PAD 20's. CVP >10. IABP 1:1. Pt was attempted on 1:2 yesterday but SVO2 decreased to <60. Pulses palpable to all extremeties. IABP site without bleeding or drainage. Good capi refill and pulses to Rt leg. Heparin off since MN.\n\nGI/GU: TF off since midnight. OGT clamped. Protonix. BS hypoactive. Foley cath. Good UO. Urine yellow with sediment.\n\nID: Gent level sent this am. Pt on vanco and zosyn. Received gent iv x1 yesterday.\n\nEndoc: RISS\n\nPlan: To OR this am. Monitor lytes and hct. Wean levophed. Continue current antibiotics. Contact precautions. SBP >90, MAP >65.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-22 00:00:00.000", "description": "Report", "row_id": 1510409, "text": "ROS:\n\nNeuro: A+O x's 3. MAEs x's 4, LLE very weak and unable lift leg. Ultram for pain mngt w/good effect.\n\nCV: RSR w/o ectopy. VSS. Peripheral pulses palp w/ease. Sternal drsg . Amiodarone and metoprolol. Metoprolol dose decreased.\n\nResp: Trach over noc 30 % cool neb. Sats 95% or >. Lungs clear and diminished in bases. Trach site wnl.\n\nGI: TF infusing over noc at 85 cc/hr via G/J tube. Abd soft w/active bowels sounds. Passing flatus. Liq stool x's 1.\n\nGU: Foley patent draining clear yellow urine in QS.\n\nEndo: FSG covered w/RSSI.\n\nLABS: AM labs pending at time of this note.\n\nSocial: No contact from family this shift\n\nPlan: Rehab screen today. Pulmonary toileting. PM valve this AM. PT for strengthening. Mobilize. Monitor, tx, support, and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-22 00:00:00.000", "description": "Report", "row_id": 1510410, "text": "Respiratory Care\nPt remains on 35% trach mask. PMV off throughout this shift and cuff remains deflated. Suctioned for thick tan plug, and scant tan thick secretions after that. BS diminished bilaterally. MDI Flovent given as ordered. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-22 00:00:00.000", "description": "Report", "row_id": 1510411, "text": "Trach downsized to #6 by NP , VSS, RIJ 3x lumen CVC DC'd, pressure applied until hemostasis attained, transfer to in PM as scheduled\n" }, { "category": "Nursing/other", "chartdate": "2174-03-31 00:00:00.000", "description": "Report", "row_id": 1510341, "text": "S/P MVR .SEE CAREVUE FOR Q15\"-60\" VS, Q1H I&O, Q2H NEURO,RESTRAINT ASSESS, Q2-4H CV/PULM ASSESSMENTS, LABS AND ALL OTHER OBJECTIVE DATA.\n\nNEURO: ORALLY INUTBATED/SEDATED ON PROPOFOL GTT. PROPOFOL OFF AT 210O TO ASSESS NEURO STATS, OPENING EYES SPONTANEOUSLY, MAE SPONTANEOUSLY AND TO COMMANDS, PEARL. RESEDATED. PROPOFOL WEANED DOWN TO 10 MCG/KG BY 0700 FOR WEANING AND ? EXTUBATION.\n\nPAIN: PERCOCET 2 CRUSHED DOWN OGT Q6H WITH CARAFATE.\n\nPULM: CHEST TUBE DRAINAGE THICK SANGUINOUS WITH BLD CLOTS. AT , CT'S STRIPPED WITH BETTER DRAINAGE. OLD CT SITE R LATERAL CHEST DRAINING LARGE AMTS SEROSANGUINOUS, DSG CHANGED ABOUT Q1H. OLD CT SITE L LATERAL CHEST DRAINING SMALL AMTS SEROSANGUINOUS FLUID, CHANGED ABOUT Q2-3HOURS. BS COARSE/WHEEZY AT TIMES, SX'D FOR SMALL-MOD AMTS THICK BLOOD TINGED SECRETIONS, MDI RX'S STARTED. SIMV MODE UNTIL ~ 0430, CHANGED TO CPAP MODE, TOLERATED WELL. SX'D FOR SMALL AMTS THICK.\n\nCV: NSR-ST, 97-105, UNTIL ~0600 THEN IN RAF WITH VR 118-150. AMIO 150MG BOLUS AT 0615, 1.0MG GTT STARTED AT 0700. MV02 VIA CCO L SUBCLAVIAN HIGH 60'S-70, CVP 7-11. MVO2 67-68, CCO RECALED AT 0500. PITRESSING GTT AT 2.4 UNITS/HR. LEVOPHED GTT TITRATED KEEPING SBP > 90. PEDAL PULSES PALPATED.\n\nENDO: QID BS WITH SSRI COVERAGE. 2 UNITS REGULAR INSULIN SC AT 2400 AND 0600.\n\nGI: ABDOMEN SOFT, HYPOACTIVE BS. OGT TO LCS DRAINING SMALL AMTS BILIOUS FLUID. PLACEMENT CHECKED BY AUSCULTATION Q4H. CARAFATE Q6H.\n\nGU: FOLEY TO CD DRAINING QS-LARGE AMTS CLEAR YELLOW URINE.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\n\nPLAN: CONTINUE TO WEAN FROM VENT AND EXTUBATE AS TOLERATED. MONITOR CT DRAINAGE Q1H, CHANGE OLD CT DSG PRN. WEAN LEVOPHED AS TOLERATED KEEPING SBP >90. ? DECREASE PITRESSING GTT. DECREAE AMIODARONE GTT TO 0.5MG/KG AT 1300.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-01 00:00:00.000", "description": "Report", "row_id": 1510345, "text": "RESP CARE: Pt remains intubated/on vent on settings per carevue. PS increased to 12 to allow pt to rest overnight, decrease WOB. ABGs reveal resp/met alkalosis. Lungs coarse, sxd mod amt thick bld tinged sputum. RSBI this am 51. Pt placed on 5 pS/5 PEEP/.50 per PA.Plan is to attempt extubation today.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-01 00:00:00.000", "description": "Report", "row_id": 1510346, "text": "PATIENT CONTINUES TO BE IN AFIB TREATED WITH TOTAL OF 20MG LOPRESSOR TO KEEP HR LESS THAN 110 AND TO KEEP SBP 150, ALSO AMIODAORNE IV DCD STARTED ON PO AMIODARONE THIS AM, HAS STANDING ORDER OF IV LOPRESSOR Q6HRS ALONG WITH VASOTEC AS WELL. THIS PM NTG STARTED TO CONTROL SBP PLAN TO WEAN AS LOPRESSOR AND VASOTEC ARE GIVEN AT 1730 NTG WEANED TO 1MCG/KG/. PATIENT TMAX 100.2.CONTINES ON IV ZOSYN/VANCOMYCIN FOR PNEUMONIA.PLAN TO CHECK VANCO TROUGH AT , NEED TO INCREASE VANCO TO 1000MG Q12HRS. RESP EXTUBATED BY 8AM, CONTINUES TO WEAR 100%SHOVEL/4LNP WITH SATS 925TO 1005 DEPENDING ON PATIENT'S ACTIVITY LEVEL IE. TALKING, COUGHING. AFTER EXTUBATION APPROX. 375CC DUMP FROM LPLEURAL CT, CXR REVEALED EFFUSIONS.THIS PM WITH MOVE TO CHAIR LEFT PLEURAL CT DRAINED 200CC SEROSANG FLUID . THIS AM MEDIASTINAL CT DCD, WIRES DCD. AT 1400 HEPARIN 800U/HR STARTED WITH NO BOLUS , NEEDS PTT AT . BVILATERAL BS CLEAR DECREASED AT BASES. OLD RIGHT PLEURAL CTSITE BAGGED D/T LOTS OF SEROSANG. DRAINAGE.. OLD LEFT PLEURAL CT DSD D/I. GI SPEECH AND SWALLOW BY TO EVALUATE POOR SWALLOWING , ONLY GIVE MEDS IN APPLESAUCE OR PUDDING. PATIENT SWALLOWED PILLS THIS PM WELL IN UPRIGHT POSITION. ABD. SOFT PRESENT BS. GU URINE DRAINING YELLOW SEDIMENT URINE, LASIX 20MG IV GIVEN AT 1600WITH FAIR RESPONSE SO FAR. NEURO PATIENT RAMBLING INCOHERENT WORDS AT TIMES, OTHER TIMES ABLE TO EXPRESS APPROPIATELY, OX1 TO SELF, NEEDS REORIENTING TO TIME/PLACE, COOPERATIVE WITH CARE, ABLE TO FOLLOW SIMPLE COMMAND. SKIN, BUTTOCKS WITH RAISED RED , WOUND RN APLLY ALOEVEST OINTMENT WITH MICONAZOLE APPLY . PATIENT CONTINUES WITH CSL AND MULTIPODUS BOOTS. PEDAL PULSES PALABLE. AT 1600 HOYERED OOB TO CARDIAC CHAIR DID WELL, WIFE AND DAUGHTER AT BEDSIDE MOST OF THE AFTRENOON.PATIENT NEED DOBBOFF TUBE IN AM IF UNABLE TO EAT. ALSO 1ST DOSE OF COUMADIN 2.5MG PO GIVEN TONIGHT...\n" }, { "category": "Nursing/other", "chartdate": "2174-04-02 00:00:00.000", "description": "Report", "row_id": 1510347, "text": "NEURO: lethargic, arouses to voice. Ox1-2 to \"\" but making confused statements, talking to people not in room. following commands. MAE on bed. PERRL.\nCV: a fib. rate mostly 90's. SBP 130's-150's. tolerating lopressor IV, lasix IV and vasotec IV. large amount periph. edema. DP/PT palp. heparin gtt increased to 1000. will recheck PTT 0600. HCT stable.\nRESP: lungs with crackles at R base, diminished L base. cool nebs face tent on pt coughing ?productive, pt swallowing. chest tube with serosang drainage. R chest tube site with bag on, moderate amt sang drainage. MD and eval. CXR done. showed increased pulm edema. good response to lasix IV, diuresed approx. 1L to 20 mg IV. R ches tube site continues with bag, drainage increased with turns in bed.\nGI/GU: abd soft, +bowel sounds had small liquid BM x1. foley with yellow-->light yellow urine.\nENDO: blood gluc not requiring RISS.\nID: afebrile this shift. vanco trough drawn, MD notified. no orders rec'd.\nSKIN: yeast to back/coccyx antifungal and aloevesta applied. sternum with steristrips dsd changed. mediastinal chest tube site with pressure dressing intact. R chest tube site with bag. site slightly pink. L thoracotomy site dsd changed.\nSOCIAL: no calls this shift.\nA/P: continue to monitor cv, resp, mental status. monitor chest tube drainage and HCT, PTT check q 6 hours until therapeutic x2. skin care, lytes repletion with diuresis. needs q day coumadin order. ?vanco order to be changed to q 12 hours.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-02 00:00:00.000", "description": "Report", "row_id": 1510348, "text": "7A-7P\nNEURO: ALERT. ORIENTED TO SELF AND YEAR, AT TIMES TO PLACE. CONSISTENTLY FOLLOWS COMMANDS. MAE. PERRLA. MUMBLING/CONFUSED SPEECH. AFEBRILE. NO C/O PAIN. FAMILY VISIT TODAY.\n\nCV: AFIB RATE 90-110'S. RARE PVCS NOTED. LYTES REPLETED . SBP 120-140S. TOLERATING IV METOPROLOL / IV VASOTEC. DOPPLERABLE PULSES BILAT. HEPARIN GTT INCREASED TO 1500UNITS/HR FOR SUBTHERAPEUTIC PTT. NEXT PTT DUE AT 2200.\n\nRESP: LS CRACKLES R LOBE CL/DIM ON L. CXR BILAT INFILTRATES. 02 SAT >95% 2LNC AND 70-100% FACETENT. (+)COUGH. CT TO 20CM SUCTION. MODERATE AMOUNTS S/S DRAINAGE. NO AIRLEAK. R CHEST TUBE SITE DRAINING SCANT AMOUNTS S/S DRAINAGE INTO COLLECTION BAG.\n\nGU/GI: GOOD HUO. IV LASIX (+)DIURESIS. ABD SNT (+)BS. LIQUID BROWN BM X1.\n\nENDO: FSBS COVERAGE PER CSRU PROTOCOL.\n\nSEE CAREVUE FOR SKIN ASSESSMENT.\n\nPLAN: MONITOR CV/RESP STATUS. CONTINUE HEPARIN GTT. PTT DUE @ 2200. CONTINUE WIHT DIURETIC AND ANITBIOTIC THERAPY. PLACE DOPHOFF FOR NUTRITION SUPPLEMENT.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-04-05 00:00:00.000", "description": "Report", "row_id": 1510353, "text": "1900-0700:\nneuro: alert and oriented x 3, appropriate. perrl. denies pain.\n\ncv: sr 70-80's, no ectopy. sbp 120-140's. amiodarone gtt d/c'd. heparin gtt restarted at 1200 units/hour. ptt pending at 0700. coumadin 3 mg po given. easily palpable pedal pulses bilaterally. cold dusky bilateral feet, md bridges aware. unable to change cortus over wire to tlc. piv placed in left hand.\n\nresp: lungs clear, diminished bilateral bases. o2 sat 95-98% on 3l nc. ct to 20 cm sxn, no airleak. minimal drainage. respiratory alkalosis noted on abg, corrected by self. po2 77-95.\n\ngi/gu: abd soft, nd. bs positive. tol po without any s/s of aspirations. pills crushed in pudding. foley to gravity, good huo. lasix . cr wnl.\n\nendo: fs qid, cover per riss.\n\nplan: monitor respiratory status. picc line for iv antibiotics. reeval swallowing. continue with heparin gtt and daily coumadin doses.\n" }, { "category": "Nursing/other", "chartdate": "2174-04-05 00:00:00.000", "description": "Report", "row_id": 1510354, "text": "NEURO: Alert, oriented x 3, MAE, transfers with 2person assist bed/chair twice today, denies any pain, Pt worked with physical therapy and plan to visit Pt daily\n\nRESP: On 2L NC, Sats 96% or higher, LS clear at apices/dim at bases, resp reg/unlabored\n\nCV: NSR with HR in 80-90s, SBP 110-140s, continues on heparin drip at 1200units, last PTT was 74, given 3mg Coumadin PO\n\nGI/GU: Appetite improving, ate better than yesterday, crushed pills with apple sauce, abd soft, BS present, no BM, Foley in place draining yellow/clear urine\n\nENDO: On SSRI\n\nSOCIAL: Family at bedside for most of the afternoon.\n\nPLAN: Continue to monitor resp, cv, urine output, lytes, increase activity as tolerated, encourage to eat as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2174-04-06 00:00:00.000", "description": "Report", "row_id": 1510355, "text": "7P-7A\nNEURO: A/Ox3. Pleasant and cooperative with care. PERRLA. MAE. PT states difficulty making connections. Consistently follows commands. Afebrile. No c/o pain.\n\nCV: NSR-ST 80-100's. No ectopy. SBP 120-140's. PO Metoprolol, PO Amiodarone continue. Palpable pulses bilat. Compression sleeves for DVT prophylaxis. Heparin GTT continues as ordered.\n\nRESP: LS cl diminished at bases. O2 sat >95% 2L NC.\n\nGU/GI: Foley to gravity with adequate HUO. PO Lasix with (+)diuresis. Abd snt (+)BS. Loose BMx1 guiac (-). PPI for GI prophylaxis. Tolerating ordered diet, pills crushed in applesauce.\n\nSEE CAREVUE FOR SKIN ASSESSMENT.\n\nENDO: FSBS coverage per CSRU protocol.\n\nPLAN: Monitor CV/RESP status. Continue Heparin GTT / daily Coumadin. Pulmonary toilet. PICC line for antibiotic therapy.\n" }, { "category": "Radiology", "chartdate": "2174-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950686, "text": " 8:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR with high WBC, FTW and pleural effusion. s/p\n trach\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with recent MVR, leukocytosis, status post trach.\n\n AP SUPINE PORTABLE CHEST: Compared to study of twelve hours prior. There has\n been interval removal of the endotracheal tube and placement of a tracheostomy\n tube in apparent satisfactory position. The right lung apices are excluded on\n this film. There is persistent right upper lobe consolidation and worsening\n left upper lobe consolidation. NG tube in the proximal stomach with the side\n port at the level of the diaphragm. Median sternotomy wires are intact.\n\n IMPRESSION:\n 1) S/p tracheostomy tube placement.\n 2) Persistent right upper lobe and worsening left upper lobe consolidations.\n 3) NG tube tip in the proximal stomach with its side port at the level of\n diaphragm, for optimal placement, this could be advanced 5 cm.\n 4) Lung apices excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950236, "text": " 8:26 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: confirm ett placement\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR.\n\n REASON FOR THIS EXAMINATION:\n confirm ett placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Mitral valve replacement. Confirm ETT placement.\n\n Single portable radiograph of the chest demonstrates a nasogastric tube with\n its tip in the stomach. There is an endotracheal tube with its tip at the\n level of the clavicular heads. Right internal jugular central venous catheter\n is present with its tip at the atriocaval junction. Cardiomediastinal contour\n is similar to that seen on the radiograph obtained several hours prior.\n Bilateral pleural effusions are again noted. Increased airspace opacity\n involving both lungs remains similar in appearance. The patient is status\n post median sternotomy.\n\n IMPRESSION:\n\n Support lines as described.\n\n CHF, unchanged. Pneumonia is not excluded.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950575, "text": " 8:54 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate for PTX.\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR with high WBC, FTW and pleural effusion. s/p\n thoracentecis L.\n REASON FOR THIS EXAMINATION:\n Evaluate for PTX.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVR with leukocytosis and pleural effusion. Status\n post thoracentesis. Evaluate for pneumothorax.\n\n COMPARISON: Chest radiographs through .\n\n TWO UPRIGHT AP CHEST RADIOGRAPHS: Again seen is small residual right upper\n lobe consolidation, similar in appearance to prior exam. There is reduction\n in the mild hazy opacity that was seen over the left hemithorax, presumably\n from recent thoracentesis. Additionally, there is lucency over the left\n hemidiaphragm which is concerning for a pneumothorax. No definite\n pneumothorax is seen in the left apex or along the left lateral hemithorax.\n The cardiac and mediastinal contours are within normal limits. Scoliosis of\n the spine is noted with no suspicious lytic or sclerotic lesions.\n Endotracheal tube is seen approximately 5.8 cm above the carina. Right\n internal jugular venous catheter is seen with the tip in the distal superior\n vena cava or cavoatrial junction. Nasogastric tube is seen with the tip\n overlying the stomach and could be advanced to ensure that side ports are\n within the stomach. No pneumoperitoneum.\n\n IMPRESSION:\n\n 1. Lucency over the left hemidiaphragm is concerning for pneumothorax.\n Recommend expiratory and/or right lateral decubitus films to further evaluate\n for pneumothorax. These results were conveyed to , NP, for\n cardiothoracic surgery, at 11:15 on .\n\n 2. Unchanged right upper lobe consolidation.\n\n 3. Nasogastric tube with tip in the stomach, which could be advanced to\n ensure that sideholes are within the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 951493, "text": " 8:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate infiltrate\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR with high WBC, FTW and pleural effusion.\n\n REASON FOR THIS EXAMINATION:\n evaluate infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n Comparison to multiple prior radiographs, dating between and\n .\n\n INDICATION: Infiltrate.\n\n Tracheostomy tube and right internal jugular vascular catheter unchanged in\n position. Cardiac and mediastinal contours are stable allowing for patient\n rotation. Right upper lobe consolidation is unchanged allowing for positional\n differences, but shows improvement compared to older radiograph of . However, there is worsening opacification in both lower lung regions,\n left greater than right. Focal left upper lobe opacity is unchanged. There\n are probable bilateral pleural effusions present, left greater than right.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-08 00:00:00.000", "description": "P ART EXT (REST ONLY) PORT", "row_id": 950073, "text": " 2:53 PM\n ART EXT (REST ONLY) PORT; ART DUP EXT LO UNI;F/U PORT Clip # \n Reason: please perfom aterial non invasive studies on extemitie\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with\n REASON FOR THIS EXAMINATION:\n please perfom aterial non invasive studies on extemities including PV,\n ABI, doppler. Also please assess L femoal atery fo dissection after angio.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Lower extremity arterial noninvasives and unilateral lower extremity\n arterial duplex.\n\n REASON: Cool right foot status post catheterization.\n\n Doppler waveform analysis reveals a triphasic waveform at the right common\n femoral, superficial femoral, popliteal, and posterior tibial arteries. The\n dorsalis pedis signal was absent. The right ankle-brachial index is 1.10. On\n the left, there are triphasic waveforms at the common femoral, superficial\n femoral, popliteal, posterior tibial, and dorsalis pedis with an\n ankle-brachial index of 1.07.\n\n Pulse volume recordings reveal normal waveforms bilaterally down through the\n ankle. On the right metatarsal, there is a flat tracing. On the left, there\n is normal metatarsal waveform.\n\n IMPRESSION: Severe flow deficit to the right foot.\n\n Duplex evaluation was performed in the left groin vessels. The common femoral\n artery and vein, superficial femoral artery and the profunda are all widely\n patent with normal waveforms. There is no evidence of dissection.\n\n IMPRESSION: Severe flow deficit to the right foot and no evidence of\n dissection in the left groin.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 951370, "text": " 8:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for source of wbc\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR with high WBC, FTW and pleural effusion.\n\n REASON FOR THIS EXAMINATION:\n eval for source of wbc\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Increased white cell count. Pulmonary infiltrates.\n\n A single AP view of the chest obtained at 08:05 hours and compared with\n the prior radiograph performed on . Tracheostomy remains in place.\n There remains airspace disease in the apices bilaterally, more marked on the\n right side. When compared with the prior radiograph, this appears to be\n improving on the right side and is also slightly improved on the left side. On\n the current examination, the patient has, however, developed increased density\n in the retrocardiac area on the left side with ill definition of the cardiac\n border consistent with air space disease/atelectasis at the left base. There\n is also likely a left pleural effusion. A right-sided IJ line is unchanged in\n position.\n\n IMPRESSION:\n\n Improving airspace disease at both apices. Developing airspace\n disease/atelectasis/effusion at the left base.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-07 00:00:00.000", "description": "TRANSCATH EMBO", "row_id": 949813, "text": " 8:01 AM\n TRANSCATH EMBO; ABDOMINAL AORTOGRAM Clip # \n -59 DISTINCT PROCEDURAL SERVICE; ANGIO PELVIC\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: RESECTION ANEURYSM AORTICABDOMINAL IN OR, RETROPERITONEAL BLEED\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n FINAL REPORT\n Please see CareWeb Notes for the complete operative report.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-11 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 950404, "text": " 3:12 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: ruq and rlq tenderness\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with\n REASON FOR THIS EXAMINATION:\n ruq and rlq tenderness\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old status post mitral valve replacement, now with right\n upper and right lower quadrant pain.\n\n LIMITED ABDOMINAL ULTRASOUND: Compared to abdominal CT of . Please\n note that the spleen and left kidney were suboptimally imaged due to overlying\n bandaging. Limited assessment of the hepatic parenchyma demonstrates no focal\n lesions. There is no intra- or extrahepatic biliary ductal dilatation. The\n gallbladder is minimally distended, filled with sludge, and demonstrates trace\n wall edema along its hepatic interface. Negative son sign.\n No pericholecystic fluid. No ascites. Small-to-moderate bilateral pleural\n effusions are noted. The right and left kidneys measure 11.2 and 12.6 cm\n bilaterally. No hydronephrosis. The left kidney is not well evaluated for\n focal lesions. The main portal vein is patent with appropriate hepatopetal\n flow and waveforms. The spleen is not well visualized.\n\n IMPRESSION:\n 1) Sludge-filled gallbladder with trace wall edema; negative son\n sign, however, if there is clinical concern for cholecystitis, a HIDA\n scan may be helpful.\n 2) Small-to-moderate bilateral pleural effusions.\n 3) Spleen and left kidney not well imaged due to overlying bandaging.\n 4) Cystic pancreatic tail lesion not imaged; as recommended on the prior CT,\n MRI is advised for further assessment.\n 5) Known left retroperitoneal hematoma is not imaged on this study.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-01 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 949047, "text": " 10:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: resp distress with 150 cc drainage from CT site.\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p VR\n\n REASON FOR THIS EXAMINATION:\n resp distress with 150 cc drainage from CT site.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Draining from chest tube.\n\n Rotated positioning, limiting assessment of the cardiomediastinal\n silhouette.\n\n S/p sternotomy. Chest tubes are present at the right and left lung bases.\n There appears to be a loculated pneumothorax in the right upper zone. There is\n patchy interstitial and alveolar opacity throughout both lungs, which could\n reflect the presence of CHF, with alveolar edema. No gross effusion is\n identified.\n\n Apparent vascular sheath on the left, which does not reach the SVC.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 949291, "text": " 6:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line position\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p VR\n\n REASON FOR THIS EXAMINATION:\n line position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: _____ line position.\n\n CHEST, SINGLE AP VIEW, PORTABLE.\n\n There is rotated positioning. Allowing for this, the cardiomediastinal\n silhouette appears unchanged. Probable background cardiomegaly. There is\n increased retrocardiac density, consistent with left lower lobe collapse\n and/or consolidation. There are patchy alveolar opacities in the right and\n left upper zones and at the right base. There is blunting of both\n costophrenic angles, consistent with effusions. Allowing for differences in\n technique, no gross interval change is identified. The right upper zone\n opacity may be slightly worse, but is considerably improved compared with\n . There is an area of relatively rounded lucency at the periphery of\n the right upper zone area of opacification -- this could represent either an\n adjacent bulla, a cavitating lesion, or residual pneumothorax (that had been\n described as a possible hydropneumothorax on earlier studies, but its borders\n are somewhat more distinct on the current study).\n\n IMPRESSION:\n\n 1. Continued left lower lobe consolidation and multifocal alveolar opacities,\n with probable small bilateral effusions. No gross change compared with\n .\n\n 2. Rounded lucency suggested in the right upper zone, associated with an\n alveolar opacity in this location. Differential diagnosis includes adjacent\n bulla, cavitating lesion, or residual pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 949079, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval eval\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p VR\n\n REASON FOR THIS EXAMINATION:\n interval eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post VR evaluate interval change.\n\n CHEST, SINGLE AP VIEW:\n\n Rotated positioning. Compared with one day earlier, I doubt significant\n interval change. Again seen are patchy interstitial and alveolar opacities.\n The differential diagnosis includes both CHF and infectious infiltrates.\n Subtle triangular lucency at the right lung apex is suspicious for a small\n pneumothorax. Bilateral chest tubes and left-sided sheath noted. No left-\n sided pneumothorax identified. No gross effusion seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 949369, "text": " 7:53 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: check line placement\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR. Changed out left subclavian line\n\n REASON FOR THIS EXAMINATION:\n check line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent MVR _____ left subclavian line. Check line placement.\n\n chest, 1 vw\n\n Patient is status post sternotomy, with expected postoperative prominence of\n the cardiomediastinal silhouette. There are bilateral chest tubes. There is\n alveolar opacity in both upper zones and to a lesser extent in both lower\n zones. Continued retrocardiac opacity consistent with left lower lobe\n collapse and/or consolidation. The rounded area of relative lucency in the\n right upper zone periphery is again noted. Of note, since the previous film,\n a left subclavian central line has been placed. The tip extends cephalad up\n into the neck beyond the confines of this film. No pneumothorax is detected.\n Findings discussed with covering house office Dr at\n approximately 10 pm on the evening of the exam.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-18 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 951515, "text": " 10:30 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o fluid collection s/p chole, now w/elev. WBC\n Admitting Diagnosis: MITRAL REGURGITATION\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with LLQ pain\n\n REASON FOR THIS EXAMINATION:\n r/o fluid collection s/p chole, now w/elev. WBC\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS\n\n CLINICAL HISTORY: 68-year-old man with left lower quadrant pain. Rule out\n fluid collection, status post cholecystectomy. Now with elevated white blood\n count.\n\n Comparison made to prior studies, including CT dated and angiogram\n dated .\n\n TECHNIQUE: Multiple transaxial images of the abdomen and pelvis were obtained\n after the administration of IV and oral contrast. Coronally and sagittally\n reformatted images were also obtained.\n\n CT ABDOMEN: Images of the lung bases reveal moderate bilateral pleural\n effusions with adjacent compressive atelectasis. Effusions are slightly\n larger than the prior study. There are scattered emphysematous changes and\n regions of focal atelectasis and/or scarring in the right lower lobe.\n\n The patient is post-sternotomy and mitral valve replacement. There is a\n heterogeneous, well-defined retrosternal collection adjacent to the sternotomy\n wires, measuring up 6.2 x 3.1 cm in transverse x AP dimensions, respectively.\n The collection exerts mass effect on the anterior heart. The collection most\n likely is situated anterior to the pericardium; however, given the history of\n pericardiotomy, it could reside between pericardial leaves. There is a\n smaller component lateral to the larger collection, measuring 3.4 x 1.7 cm,\n that appears to be superficial to the pericardium. The larger collection\n extends inferiorly to the mid abdomen at the level of a sugical skin staple.\n There is a small drop of gas within the collection (sequence 2, image 27). The\n overall appearance is consistent with hematoma, however, cannot exclude\n superinfection.\n\n The patient is post-placement of a gastrojejunostomy tube. The gallbladder is\n surgically absent. There is fluid in the cholecystectomy bed. This fluid is\n not contiguous with the previously mentioned retrosternal collection.\n\n The liver is otherwise unremarkable, without focal hepatic lesions. No intra-\n or extra-hepatic biliary ductal dilatation. There is a cystic lesion in the\n pancreatic tail that is unchanged since the prior study. The remainder of the\n pancreas is unremarkable. No pancreatic ductal dilatation. No significant\n (Over)\n\n 10:30 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o fluid collection s/p chole, now w/elev. WBC\n Admitting Diagnosis: MITRAL REGURGITATION\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n peripancreatic inflammatory changes. There is an irregular hypoattenuating\n region in the spleen, consistent with splenic infarct, also unchanged. The\n adrenal glands are normal.\n\n There is omental stranding, most likely representing post-surgical changes in\n this patient with recent exploratory laparotomy.\n\n There is perihepatic and perisplenic free fluid.\n\n There is a large retroperitoneal hematoma with a heterogeneous appearance. No\n discrete foci of hyper-enhancement are identified to suggest the presence of\n active hemorrhage. Abutting the hematoma posteriorly are multiple metallic\n coils from prior embolectomy of extravasating lumbar artery branch, as\n described in report of . While it is difficult to obtain a\n meaningful measurement of the retroperitoneal hematoma, a large component\n measures approximately 26 x 13 x 15 cm in the CC, transverse, and AP\n dimensions, respectively, which is substantially larger than on prior study of\n . The hematoma displaces the left kidney anteriorly. Kidneys\n otherwise are unremarkable. Streak artifact from coils limits evaluation of\n the hematoma.\n\n CT PELVIS: There is a Foley catheter in the urinary bladder, which contains\n gas but is otherwise unremarkable. Multiple metallic seeds are in the\n prostate gland. The rectum and sigmoid colon are unremarkable. There is\n pelvic free fluid. No pelvic or inguinal lymphadenopathy.\n\n There is scoliosis and degenerative changes of the lumbar spine. No\n suspicious osseous lesions.\n\n Multiplanar reformatted images were useful in delineation of the above\n findings.\n\n Findings were discussed with surgery resident, Dr. .\n\n IMPRESSION:\n 1. Massive left retroperitoneal hematoma, with interval increase in size. No\n discrete hyperdense foci to suggest active bleeding, however, given the\n substantial interval increase in size, cannot exclude continued extravasation.\n 2. Retrosternal collection extending inferiorly to upper abdomen and exerting\n mass effect on the heart. This collection is most consistent with\n postoperative hematoma, but cannot exclude the presence of superinfection.\n 3. Moderate bilateral pleural effusions with slight interval increase in\n size.\n\n\n (Over)\n\n 10:30 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o fluid collection s/p chole, now w/elev. WBC\n Admitting Diagnosis: MITRAL REGURGITATION\n Contrast: OPTIRAY Amt: 120\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950557, "text": " 7:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation and NGT placement.\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR.\n REASON FOR THIS EXAMINATION:\n s/p intubation and NGT placement.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:30 A.M., .\n\n HISTORY: Recent MVR and NG tube placement.\n\n IMPRESSION: AP chest compared to through 26:\n\n A relatively small residual of right upper lobe consolidation remains, and\n pulmonary edema has cleared from remainder of the lungs with the exception of\n the left lower lobe since . Heart size is normal. Pleural\n effusion if any is small, on the right. No pneumothorax. ET tube in standard\n placement. Cuff is inflated to the point where it distends the trachea. Tip\n of the right jugular line projects over the superior cavoatrial junction and a\n nasogastric tube ends in the upper stomach and would need to be advanced\n several centimeters to move all the side ports beyond the GE junction. No\n pneumoperitoneum.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-14 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 951053, "text": " 10:23 PM\n PORTABLE ABDOMEN Clip # \n Reason: s/p open G-J/cholecystectomy w/abdominal distention-r/o ileu\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with\n REASON FOR THIS EXAMINATION:\n s/p open G-J/cholecystectomy w/abdominal distention-r/o ileus/obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man with recent cholecystostomy and abdominal\n distention.\n\n Comparison is made to the recent CT of abdomen done on .\n\n Supine view of the abdomen, one image.\n\n Small bowel loops are mildly dilated. Gas is also noted within the colon with\n no evidence of abnormal dilatation. No definite obstructive pattern is noted.\n Gas is noted within the rectum. Free intra-abdominal air and air-fluid levels\n cannot be assessed based on the supine radiograph.The brachytherapy seeds are\n noted in the lower pelvis. Embolization coils are noted in the left lower\n quadrant. Cholecystostomy tube is noted in the right upper quadrant.\n\n IMPRESSION: Mild dilatation of the small bowel loops with no evidence of\n obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 949483, "text": " 11:50 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR. Changed out left subclavian line\n\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post recent MVR, chest tubes removed.\n\n COMPARISON: Comparison is made to study performed 3 hours earlier.\n\n Median sternotomy wires again seen. There has been interval removal of the\n left-sided chest tube. No definite pneumothorax is identified. Cardiac and\n mediastinal contours appear stable. Bilateral patchy airspace opacity is\n again noted, not significantly changed from prior.\n\n IMPRESSION: Interval removal of a left-sided chest tube without evidence of\n pneumothorax. Persistent patchy bilateral airspace opacities again possibly\n reflects edema versus multifocal pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 949835, "text": " 9:51 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o ptx. check ett placement\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR. Changed out left subclavian line\n\n REASON FOR THIS EXAMINATION:\n r/o ptx. check ett placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ETT placement.\n\n Comparison is made to prior radiograph dated and .\n\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH.\n\n When compared to most recent film, there has been interval placement of an\n endotracheal tube with its tip approximately 7 cm from the carina and a right-\n sided internal jugular central venous catheter with its tip in the cavoatrial\n junction. Focal parenchymal opacities within the right upper lobe appear\n unchanged, with mild improvement to opacity within the right lower lobe,\n however, there is a more diffuse opacity spreading from the hila within the\n left hemithorax, likely representing pulmonary edema. There is probably small\n bilateral pleural effusions. No evidence of pneumothorax. No new focal\n parenchymal consolidations identified and atelectasis within the left lower\n lobe is stable. Note is made of mild prominence to the air filled transverse\n colon which may be suggestive of underlying ileus.\n\n IMPRESSION:\n\n 1. Tip of the endotracheal tube approximately 7 cm from the carina.\n Repositioning recommended. Right internal jugular central venous catheter\n with tip in cavoatrial junction. No evidence of pneumothorax.\n\n 2. Progression of pulmonary edema.\n\n 3. Gaseous distention of the colon. This may be better evaluated with\n dedicated abdominal radiographs.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950035, "text": " 12:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR. Changed out left subclavian line\n\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man, status post recent mitral valve replacement.\n Evaluate interval change.\n\n COMPARISON: AP upright portable chest x-ray dated .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: Endotracheal and nasogastric tuebs\n have been removed. The right internal jugular central venous catheter\n remains in stable position with the tip in the right atrium. The patient is\n status post median sternotomy with mitral valve repair. Bilateral airspace\n consolidations are slightly worse than on prior exam, and there is new left\n lower lobe collapse and consolidation. A small right pleural effusion is\n slightly increased since prior exam, and there is a new moderately large left\n pleural effusion.\n\n IMPRESSION: Worsening bilateral pulmonary edema with moderate left, tiny right\n pleural effusions and relaxation atelectasis of the left lower lobe.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 949434, "text": " 8:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CT removal\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR. Changed out left subclavian line\n\n REASON FOR THIS EXAMINATION:\n s/p CT removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post recent MVR, status post chest tube removal.\n\n COMPARISON: .\n\n PORTABLE CHEST:\n\n There has been interval removal of the left-sided subclavian line. There has\n been interval removal of the right-sided chest tube. Left-sided chest tube\n again seen at the lateral left base. Mediastinotomy wires again seen. No\n definite pneumothorax identified. Cardiac and mediastinal contours appear\n stable. Slight decrease in bilateral airspace opacities is noted. Persistent\n retrocardiac opacity is seen.\n\n IMPRESSION:\n\n 1. Interval removal of left-sided subclavian and right-sided chest tube. No\n definite evidence of pneumothorax.\n\n 2. Slight decrease in persistent patchy airspace opacity, possibly\n representing edema versus multifocal infection. Persistent retrocardiac\n opacity noted.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950172, "text": " 9:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR. Changed out left subclavian line\n\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rule out pneumonia.\n\n Single portable radiograph of the chest demonstrates a persistent left-sided\n pleural effusion. There is likely a small right-sided pleural effusion.\n Assessment is limited by patient motion, but the cardiomediastinal contours\n are likely unchanged. Right internal jugular central venous catheter is again\n noted with its tip in the right atrium. The patient is status post median\n sternotomy. No pneumothorax. Increased airspace opacity involving the\n bilateral lungs remains similar in appearance. Bibasilar atelectasis is\n unchanged.\n\n IMPRESSION:\n\n Persistent increased airspace opacity involving the bilateral lungs and\n persistent left-sided pleural effusion. Findings represent CHF and are\n unchanged. Pneumonia is not excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-06 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 949689, "text": " 12:56 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o diverticulitis\n Admitting Diagnosis: MITRAL REGURGITATION\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with LLQ pain\n REASON FOR THIS EXAMINATION:\n r/o diverticulitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old male status post mitral valve replacement, now with left\n lower quadrant pain.\n\n COMPARISON: No prior cross-sectional imaging of the abdomen available. Chest\n radiographs from today.\n\n TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis\n after oral and 130 mL Optiray IV contrast with coronal and sagittal reformats.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The visualized lung bases demonstrate\n small-to-moderate bilateral pleural effusions and compressive atelectasis of\n the dependent lower lobes. There are also scattered atelectatic changes of\n the anterior portions of the lower lobes. The liver, gallbladder, adrenal\n glands, stomach, and bowel are within normal limits.\n\n There is a massive left retroperitoneal hematoma, which extends from the\n spleen down to the left groin. The hematoma measures 11.0 x 9.0 cm on\n greatest axial dimension. Two tiny foci of high density within the hematoma\n raise the possibility of slow bleeding (series 477B, images 25 and 23). A few\n small wedge-shaped peripheral hypodense lesions of the spleen are consistent\n with infarcts, the larger measuring 2.1 cm. Low density fluid around the\n spleen is likely secondary to the infarcts. In the right kidney, there are\n two small hypodense foci which measure up to 9 mm and extend to the cortex and\n may be cysts or possibly infarcts. The left kidney is within normal limits. At\n the tail of the pancreas is a 16- mm cystic lesion. The body and head of the\n pancreas are within normal limits. There is no free intraperitoneal gas or\n fluid. There is no pathologic abdominal lymphadenopathy.\n\n CT OF THE PELVIS WITH IV CONTRAST: Brachytherapy seeds are noted in the\n prostate gland. The rectum, seminal vesicles, urinary bladder, and pelvic\n loops of bowel are unremarkable. There is no free intraperitoneal pelvic\n fluid.\n\n BONE WINDOWS: There are degenerative changes of the lumbosacral spine with\n moderate convex right lumbar scoliosis noted. No suspicious osseous or\n sclerotic lesions are identified.\n\n IMPRESSION:\n 1. Massive left retroperitoneal hematoma extends from the spleen down to the\n left groin. Two small hyperdense foci within the hematoma raise the\n (Over)\n\n 12:56 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o diverticulitis\n Admitting Diagnosis: MITRAL REGURGITATION\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n possibility of slow bleeding.\n 2. Splenic infarcts.\n 3. Two subcentimeter low-density lesions of the right kidney may represent\n cysts but could be infarcts. No prior study available to compare.\n 4. 16-mm cystic lesion of the tail of the pancreas could represent cystic\n neoplasm.\n 5. Small bilateral pleural effusions and compressive atelectasis of the\n dependent lower lobes.\n\n Multiphase MR of the abdomen is suggested to evaluate the pancreatic, splenic,\n and renal lesions once the patient's acute problems have resolved.\n\n These findings were discussed with Dr. at 2:00 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950377, "text": " 7:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR.\n\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post recent mitral valve replacement. Evaluate effusion.\n\n COMPARISON: Chest x-ray .\n\n TWO AP UPRIGHT PORTABLE RADIOGRAPHS OF THE CHEST: The cardiomediastinal\n silhouette is within normal limits. There has been interval improvement of\n the left-sided pleural effusion. Again seen is opacity in the right upper\n lung field consistent with atelectasis or airspace disease. Sternal wires are\n noted, presumably from recent mitral replacement. Right IJ tube is seen with\n tip in the distal SVC or cavoatrial junction. NG tube is seen with tip\n overlying the stomach, though the side hole is not clearly seen. There is\n mild scoliosis with degenerative changes noted in the spine.\n\n IMPRESSION: Interval improvement in left-sided pleural effusion. Persistent\n right upper lobe opacification which may be due to atelectasis or airspace\n disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-04-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 949380, "text": " 10:45 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval line placement\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p recent MVR. Changed out left subclavian line\n\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post recent MVR, changed left subclavian line, evaluate\n placement.\n\n COMPARISON: Comparison is made to study performed three hours earlier.\n\n PORTABLE CHEST\n\n Left-sided subclavian line again seen with tip extending cephalad into the\n neck, with tip not completely imaged on this study. Median sternotomy wires\n and bilateral chest tubes again seen. There has been a mild interval increase\n in confluence of the right upper and lower lobe opacities. Continued\n retrocardiac opacity and alveolar airspace opacity in the left upper lobe is\n seen.\n\n IMPRESSION:\n 1. Left subclavian line again seen with tip traveling up the left IJ.\n\n 2. Increased confluence of right upper and lower lobe opacities, concerning\n for possible multifocal pneumonia.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2174-03-28 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 948275, "text": " 12:46 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Lt SCV pa line\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with CHF\n plerual effusions\n REASON FOR THIS EXAMINATION:\n Lt SCV pa line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left subclavian line placement.\n\n COMPARISON: Comparison is made to study performed four hours earlier.\n\n PORTABLE CHEST RADIOGRAPH:\n\n Intraaortic balloon pump appears slightly lower on current study, now with tip\n approximately 5 cm below the aortic knob. New left-sided subclavian line is\n seen with Swan-Ganz catheter with tip pointing downwards, possibly within a\n branch of the pulmonary artery, however, more likely coiled within the main\n pulmonary artery. There has been interval removal of the previously seen\n inferior Swan-Ganz catheter. Endotracheal tube is seen approximately 6 cm\n above the carina, with likely endotracheal cuff overinflation again seen.\n Bilateral chest tubes appear in stable position. Cardiac and mediastinal\n contours appear unchanged. Bilateral airspace opacities consistent with\n pulmonary edema appear stable. There is increased lucency at the left base,\n suggesting left basilar pneumothorax on this portable supine film.\n\n IMPRESSION:\n 1. Swan-Ganz catheter with tip likely coiled within the main pulmonary\n artery/right ventricular outflow tract.\n 2. Intraaortic balloon pump relatively low in position, with tip\n approximately 5 cm below the aortic knob.\n 3. Possible left basilar pneumothorax.\n\n The findings were discussed with Dr. immediately following\n completion of the study.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947830, "text": " 8:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute flail mitral leaflet w/hypoxia-evaluate ?CHF/ARDS\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with\n REASON FOR THIS EXAMINATION:\n acute flail mitral leaflet w/hypoxia-evaluate ?CHF/ARDS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man with acute flare of mitral leaflet hypoxia.\n Assess for CHF.\n\n PORTABLE AP CHEST: No prior studies are available for comparison purposes. An\n intra-aortic balloon pump is seen with the tip approximately 4.5 cm away from\n the takeoff of the left subclavian artery. An NG tube courses across the\n chest and out of view. There are bilateral moderate-sized pleural effusions,\n right greater than left. There is an additional parenchymal opacity in the\n right upper lung which may represent edema, but consolidation cannot be\n excluded.\n\n IMPRESSION:\n\n 1. Bilateral moderate-sized pleural effusions, right greater than left.\n\n 2. Right upper lung opacity could represent edema, but consolidation cannot\n be excluded.\n\n 3. Intra-aortic balloon pump with the tip approximately 4.5 cm from takeoff\n of left subclavian artery.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948778, "text": " 7:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess chf\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p MVR/IABP\n plerual effusions\n REASON FOR THIS EXAMINATION:\n assess chf\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of MVR .\n\n Endotracheal tube is 5 cm above carina. Tip of Swan-Ganz catheter is in right\n main pulmonary artery. Tip of NG tube is in fundus of stomach. Mediastinal\n and bilateral chest tubes in lower hemithoraces. No pneumothorax. There has\n been a slight partial resolution of the bilateral predominantly upper lobe and\n right lower zone air space opacities since the prior film of .\n\n IMPRESSION: No pneumothorax. Slight resolution of bilateral pulmonary\n opacities consistent with resolving edema.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 948185, "text": " 7:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: UNRESPONSIVENESS,R/O CVA\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with\n REASON FOR THIS EXAMINATION:\n r/o cva\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old man with unresponsiveness.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: The study is limited by motion artifact. There is no evidence of\n hemorrhage, mass effect, hydrocephalus, shift of normally midline structures,\n or infarction. The density values of the brain parenchyma are within normal\n limits. There is sphenoid, ethmoid and maxillary sinus mucosal thickening.\n Nasogastric and endotracheal tubes are noted.\n\n IMPRESSION: Limited study with no abnormalities detected. No evidence of\n hemorrhage or mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947874, "text": " 8:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval eval\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with\n plerual effusions\n REASON FOR THIS EXAMINATION:\n interval eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man with acute flare of mitral leaflet hypoxia.\n Evaluate pleural effusions.\n\n COMPARISON: AP supine portable chest x-ray dated .\n\n AP SUPINE PORTABLE CHEST X-RAY: An endotracheal tube, bilateral chest tubes,\n nasogastric tube and intra-aortic balloon pump are all unchanged position. A\n clip over ht left hilum is consistent with PDA closure. Small pleural\n effusions at bilateral lung apices are stable in size from the supine\n radiograph. No pneumothorax is seen. Moderate interstitial edema persists,\n unchanged.\n\n IMPRESSION:\n 1. Stable tiny biapical pleural effusions and interstitial edema.\n 2. No pneumothorax on this supine radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948229, "text": " 9:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion/infiltrate\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with CHF\n plerual effusions\n REASON FOR THIS EXAMINATION:\n r/o effusion/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old male with CHF.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH.\n\n Endotracheal tube seen with tip approximately 5-cm above the carina.\n Questionable overdistention of the tracheal cuff is noted, with relative\n dilation of the proximal trachea. Intraaortic balloon pump noted with marker\n approximately 3-cm from the takeoff of the left subclavian. Swan-Ganz seen\n with tip in the region of the right main pulmonary artery. Nasogastric tube\n seen with tip overlying the stomach. Bilateral chest tube seen with tips in\n relatively unchanged position.\n\n Cardiac and mediastinal contours appear relatively stable. Again seen are\n bilateral alveolar opacities, right greater than left, slightly increased\n compared to prior study. No focal consolidations are seen in the lungs. No\n evidence of pleural effusion.\n\n IMPRESSION: Worsening asymmetric alveolar pattern, likely pulmonary edema.\n Possible slight overinflation of endotracheal tube balloon cuff.\n\n" }, { "category": "Radiology", "chartdate": "2174-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948935, "text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p MVR w/dropping HCT-r/o effusion\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p MVR/IABP\n plerual effusions\n REASON FOR THIS EXAMINATION:\n s/p MVR w/dropping HCT-r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: S/P MVR with dropping hematocrit.\n\n Comparison is made with prior study performed the day before.\n\n FINDINGS: Moderate-to-severe pulmonary edema has worsened since . Cardiac size is top normal. Small bilateral pleural effusions have\n increased. ET tube is in standard position. Swan-Ganz catheter tip in the\n right main pulmonary artery. NG tube tip is in the stomach. Mediastinal and\n bibasal chest tubes remain in place.\n\n IMPRESSION: Worsened moderate-to-severe pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948668, "text": " 1:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p MVR/IABP\n plerual effusions\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post MVR.\n\n Comparison is made to prior radiographs dated and .\n\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH\n\n Since prior film, patient is now noted to be status post median sternotomy and\n mitral valve replacement with endotracheal tube approximately 5 cm from the\n carina and Swan-Ganz catheter tip slightly past the right main pulmonary\n artery. New mediastinal drains and bilateral chest tubes are identified with\n no evidence of pneumothorax. Intraaortic balloon pump is approximately 8 cm\n from the left subclavian artery with tip projecting just over the left main\n stem bronchus. Nasogastric tube sideport appears to be at gastroesophageal\n junction. There is perhaps slight improvement to bilateral mostly upper lobe\n alveolar consolidation consistent with underlying pulmonary edema. Left\n costophrenic angle remains sharp with mild blunting of the right costophrenic\n angle suggesting small underlying pleural effusion.\n\n IMPRESSION:\n 1. Tip of Swan-Ganz appears slightly past right main pulmonary artery and\n sideport of nasogastric tube appears to be at gastroesophageal junction.\n Repositioning recommended.\n\n 2. Slight improvement to bilateral alveolar consolidative process consistent\n with pulmonary edema.\n\n 3. Small right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948406, "text": " 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Fever spike\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with CHF\n plerual effusions\n REASON FOR THIS EXAMINATION:\n Fever spike\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old male with CHF, effusions, fever.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH:\n\n Endotracheal tube is seen with tip approximately 6 cm above the carina.\n Intraaortic balloon pump appears slightly lower, now with tip approximately 5\n cm below the aortic knob. Swan-Ganz catheter appears to have withdrawn\n slightly with tip within the main pulmonary artery. Bilateral chest tubes are\n seen in stable position. Bilateral alveolar opacities, right greater than\n left again seen, consistent with relatively unchanged pulmonary edema.\n\n IMPRESSION: Relatively unchanged appearance of likely asymmetric pulmonary\n edema, right greater than left. There are no focal consolidations identified.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947838, "text": " 10:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p bilat chest tube insertion-check placement\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with\n\n REASON FOR THIS EXAMINATION:\n s/p bilat chest tube insertion-check placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old male with recent chest tube insertion and acute flail\n mitral valve leaflet.\n\n Comparison is made to prior radiographs dated .\n\n SINGLE SUPINE PORTABLE CHEST RADIOGRAPH\n\n Since earlier in the day, a previously severe alveolar process in the upper\n lobes, likely pulmonary edema, has improved. Previous, moderate pleural\n effusions have decreased after insertion of a pleural tube in each hemithorax\n coursing inferomedially. There is no evidence of pneumothorax on this supine\n radiograph.\n\n Cardiomediastinal silhouette and hilar contours are normal.\n Unchanged in position are an endotracheal tube ending 6 cm from the carina, a\n nasogastric tube ending in the stomach, and an intraaortic balloon pump with\n its tip just above the left main stem bronchus.\n\n IMPRESSION:\n 1. Small pleural effusions, decreased following insertion of pleural tubes.\n No pneumothorax.\n\n 2. Moderately severe improving upper lobe pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2174-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948294, "text": " 2:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: PA repositioned\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with CHF\n plerual effusions\n REASON FOR THIS EXAMINATION:\n PA repositioned\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old male with CHF and pleural effusions with repositioning\n of Swan-Ganz catheter.\n\n Comparison is made to prior radiographs from earlier in the day at\n approximately 9:20 and approximately 13:10.\n\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH:\n\n A left subclavian Swan-Ganz catheter is again identified with its tip\n appearing to be coiled within the main pulmonary artery. Tip of endotracheal\n tube is in standard position approximately 5 cm from the carina and tip of\n aortic balloon pump is approximately 3 cm from the left subclavian artery.\n Nasogastric tube is unchanged in position within the stomach. Bilateral\n alveolar opacities, mostly involving the upper lobes and with right greater\n than left side involvement is unchanged likely representing pulmonary edema.\n No large pleural effusions or pneumothoraces are identified. Bilateral chest\n tubes are stable.\n\n IMPRESSION: 1) Swan-Ganz catheter likely coiled within main pulmonary artery.\n\n 2) Unchanged asymmetric upper lobe alveolar opacities, right greater than\n left side, likely representing pulmonary edema.\n\n\n" }, { "category": "Echo", "chartdate": "2174-03-30 00:00:00.000", "description": "Report", "row_id": 84650, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for MVR\nStatus: Inpatient\nDate/Time: at 15:19\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast in the body\nof the LAA. No mass/thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast in the body of\nthe RA. A catheter or pacing wire is seen in the RA and extending into the RV.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness. Moderately dilated LV cavity. Normal\nregional LV systolic function. Overall normal LVEF (>55%). [Intrinsic LV\nsystolic function likely depressed given the severity of valvular\nregurgitation.]\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Moderate global RV free wall hypokinesis.\n\nAORTA: Normal ascending aorta diameter. Focal calcifications in ascending\naorta. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Partial mitral leaflet flail. Mild mitral annular calcification.\nNo MS. (4+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. Suboptimal image quality. The rhythm appears to be atrial\nfibrillation. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nPRE CPB The left atrium is markedly dilated. No spontaneous echo contrast is\nseen in the body of the left atrium or left atrial appendage. No mass/thrombus\nis seen in the left atrium or left atrial appendage. Mild spontaneous echo\ncontrast is seen in the body of the right atrium. No atrial septal defect is\nseen by 2D or color Doppler, though can not completely rule out a small PFO.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\nmoderately dilated. Regional left ventricular wall motion is normal. Overall\nleft ventricular systolic function is normal (LVEF>55%). [Intrinsic left\nventricular systolic function is likely more depressed given the severity of\nvalvular regurgitation.] There is moderate global right ventricular free wall\nhypokinesis. There are simple atheroma in the descending thoracic aorta. An\nintraaortic balloon is seen (IABP). It's tip is about 4 cm below the distal\narch. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion. There is no aortic valve stenosis. No aortic regurgitation\nis seen. There is partial posterior mitral leaflet flail. Severe (4+) mitral\nregurgitation is seen. The mitral regurgitation jet is eccentric. There is a\ntrivial/physiologic pericardial effusion.\n\nPOST CPB The patient is receiving epinephrine and norepinephrine by infusion.\nRV systolic function is somewhat improved - now mildly globally hypokinetic.\nLV systolic function is normal. There is a bioprosthesis in the mitral\nposition. It is well seated and both leaflets demonstrate normal excursion.\nThe maximum gradient across the MV was 7 mm Hg with a mean gradient of 5.\nThere is trace valvular MR. The thoracic aorta appears intact.\n\n\n" }, { "category": "Echo", "chartdate": "2174-03-25 00:00:00.000", "description": "Report", "row_id": 84651, "text": "PATIENT/TEST INFORMATION:\nIndication: Mitral valve prolapse. Severe mitral regurgitation\nHeight: (in) 72\nWeight (lb): 192\nBSA (m2): 2.10 m2\nBP (mm Hg): 105/49\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 17:20\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets.\n\nMITRAL VALVE: Myxomatous mitral valve leaflets. Moderate/severe MVP. Partial\nmitral leaflet flail. Mitral leaflets fail to fully coapt. No mass or\nvegetation on mitral valve. Severe (4+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: TVP. Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). No TEE related complications.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. Left ventricular\nsystolic function is hyperdynamic (EF>75%). Right ventricular systolic\nfunction is normal. The ascending, transverse and descending thoracic aorta\nare normal in diameter and free of atherosclerotic plaque. The aortic valve\nleaflets are mildly thickened. The mitral valve leaflets are myxomatous. There\nis moderate/severe mitral valve prolapse. There is partial mitral leaflet\nflail of the posterior leaflet (?P2). The mitral valve leaflets do not fully\ncoapt. No mass or vegetation is seen on the mitral valve. Severe (4+) mitral\nregurgitation is seen. The mitral regurgitation jet is eccentric (anteriorly\ndirected). Tricuspid valve prolapse is present. There is mild pulmonary artery\nsystolic hypertension. The pulmonic valve leaflets are thickened. There is no\npericardial effusion.\n\nIMPRESSION: MVP with a flail posterior leaflet and severe, eccentric mitral\nregurgitation. No valuvlar vegetations or abcess seen. Hyperdynamic LVEF.\n\n\n" }, { "category": "ECG", "chartdate": "2174-03-30 00:00:00.000", "description": "Report", "row_id": 207670, "text": "Sinus rhythm. Normal ECG. Compared to the previous tracing of sinus\nrhythm has appeared. Otherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2174-03-29 00:00:00.000", "description": "Report", "row_id": 207671, "text": "Atrial fibrillation\n\n" } ]

[ { "category": "Radiology", "chartdate": "2122-07-27 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1198892, "text": " 4:33 PM\n CHEST (SINGLE VIEW); -76 BY SAME PHYSICIAN # \n Reason: position of the PICC line\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with metastaic breast ca\n REASON FOR THIS EXAMINATION:\n position of the PICC line\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC placement.\n\n FINDINGS: In comparison with the earlier study of this date, the right\n subclavian PICC line has been re-positioned with the tip in the lower portion\n of the SVC. Little change in the appearance of the heart and lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1198828, "text": " 10:47 AM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: 50 cm R brachial PICC Issy pg# \n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with port infection\n REASON FOR THIS EXAMINATION:\n 50 cm R brachial PICC Issy pg# \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 51-year-old woman with port infection in right brachial PICC\n placement.\n\n COMPARISON: Chest radiograph from .\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume and show bilateral focal airspace opacities. The\n cardiac silhouette is enlarged. The mediastinal silhouette and hilar contours\n are normal. There may be small bilateral pleural effusions. A right-sided\n chest tube is noted overlying the expected location of the right lower lung.\n A right-sided PICC line passes out of view into the internal jugular vein.\n\n IMPRESSION:\n\n Right-sided PICC line passes out of view into the right internal jugular vein\n and should be removed.\n\n These findings were communicated to via telephone at 13:55 on\n .\n\n" }, { "category": "Radiology", "chartdate": "2122-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198640, "text": " 1:36 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: removal of L apical CHEST TUBE\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p vats\n REASON FOR THIS EXAMINATION:\n removal of L apical CHEST TUBE\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left apical tube removed, evaluate for pneumothorax.\n\n CHEST: The left apical tube has been removed and there is no evidence of a\n pneumothorax. The three right chest tubes remain. No other changes are seen.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1199524, "text": " 11:23 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for hemothorax/effusion/pna\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with recent b/l VATS now with more decr right sided BS\n REASON FOR THIS EXAMINATION:\n evaluate for hemothorax/effusion/pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old woman with recent bilateral VATS, now with more\n decreased right-sided breath sounds. Evaluate for pneumothorax, effusion or\n pneumonia.\n\n COMPARISON: Multiple chest radiographs, the latest from .\n\n TWO VIEWS OF THE CHEST:\n\n The lungs are low in volume and show bilateral lower lobe opacities with small\n associated effusions. The cardiac silhouette is enlarged. The mediastinal\n silhouette and hilar contours are normal. A right-sided PICC line terminates\n in the distal SVC appropriately. Mild right pleural thickening likely relates\n to recent procedure.\n\n IMPRESSION:\n\n Mild bibasilar opacities could represent atelectasis or sequelae of\n aspiration. Small if any bilateral effusions. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-27 00:00:00.000", "description": "EXCH PERPHERAL W/O PORT", "row_id": 1198868, "text": " 2:43 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Picc reposition\n Admitting Diagnosis: PORT INFECTION\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with picc in neck\n REASON FOR THIS EXAMINATION:\n Picc reposition\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Reposition PICC.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGISTS: Dr. , Dr. , Dr. .\n\n TECHNIQUE: The patient was placed supine on the angiography table in standard\n position. The position of the right upper extremity PICC was determined under\n fluoroscopy to be within the right axillary vein. Using sterile technique, a\n guidewire was placed through the PICC and into the right atrium. The PICC was\n then removed over the guidewire. A peel-away sheath was then placed over the\n guidewire and a double-lumen PICC line measuring 49 cm in length was then\n placed through the peel-away sheath, over the guidewire, with its tip\n positioned in the low SVC under fluoroscopic guidance. Position of the\n catheter was confirmed by a fluoroscopic spot film of the chest. The\n peel-away sheath and guidewire were then removed. The catheter was secured to\n the skin, flushed, and a sterile dressing applied. The patient tolerated the\n procedure well. There were no immediate complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange via the\n right upper extremity. The new PICC is a double-lumen catheter measuring 49\n cm, with the tip positioned in the low SVC. The line is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198716, "text": " 9:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pneumothorax\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with empyema, interval removal of Chest tubes\n REASON FOR THIS EXAMINATION:\n ?pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Empyema with interval removal of chest tube, to assess for\n pneumothorax.\n\n FINDINGS: There has been removal of one chest tube on the right with the two\n remaining. No evidence of pneumothorax. Overall appearance is quite similar,\n though the degree of opacification along the right lateral chest wall that may\n reflect previous empyema is much less prominent.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1199132, "text": " 6:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PTX STAT\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p R decort, CT fell out\n REASON FOR THIS EXAMINATION:\n eval for PTX STAT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old woman, status post right decortication and a chest\n tube fell out, here to evaluate for pneumothorax.\n\n COMPARISON: Chest radiograph from .\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume and show bilateral lower lobe opacities. The\n cardiac silhouette is enlarged. The mediastinal silhouette and hilar contours\n are normal. There are small bilateral pleural effusions, larger on the right,\n unchanged from prior. No pneumothorax is present. A right-sided PICC line\n appears to terminate in the right atrium.\n\n IMPRESSION:\n\n No pneumothorax. Bilateral lower lobe atelectasis with associated effusions.\n\n Right PICC line is in the right atrium.\n\n These findings were communicated to , MD at 12:00 pm on\n .\n\n" }, { "category": "Radiology", "chartdate": "2122-07-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1198677, "text": " 7:09 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: PICC exchange 38cm right basilicIsabel #\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with need for DL PICC\n REASON FOR THIS EXAMINATION:\n PICC exchange 38cm right basilicIsabel #\n ______________________________________________________________________________\n WET READ: MXAk SAT 7:30 PM\n Picc line exchanged with tip in distal SVC. No other changes in comparison to\n prior study from 6 hours ago.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC exchange.\n\n FINDINGS: In comparison with the earlier study of this date, the PICC line\n has been exchanged and the tip remains in the mid portion of the SVC.\n Otherwise, no change.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1198796, "text": " 9:04 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate empyemas, chest tube drainage, waterseal\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51F with bilateral empyemas and bacteremia with x 2 CTs on right to waterseal\n REASON FOR THIS EXAMINATION:\n evaluate empyemas, chest tube drainage, waterseal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with bilateral empyema and bacteremia with right sided\n chest tube to waterseal. Please evaluate empyema.\n\n COMPARISON: Multiple chest x-rays during this hospitalization, latest one\n being on , approximately 24 hours before this exam.\n\n TECHNIQUE: PA and lateral chest x-ray.\n\n FINDINGS: Low lung volumes are stable from prior exam after accounting for\n difference in technique and position of the patient. A right-sided PICC is\n observed with the tip in stable position mid-to-distal SVC. A chest tube is\n seen directed towards the right cardiophrenic angle which is unchanged. A\n right-sided apical chest tube has been withdrawn since prior exam. Cardiac\n size impossible to assess due to poor lung exapnsion. Overall appearance of\n the lungs is unchanged. Bilateral pleural effusions present. No evidence of\n pneumothorax.\n\n IMPRESSION:\n 1. Chest tube ending in right apex has been withdrawn.\n 2. No evidence of pneumothorax.\n 2. Overall appearance of chest structures unchanged from prior chest X-ray on\n .\n\n" }, { "category": "Radiology", "chartdate": "2122-08-02 00:00:00.000", "description": "RENAL U.S.", "row_id": 1199774, "text": " 11:57 AM\n RENAL U.S. Clip # \n Reason: hydronephrosis?\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with metastatic breast CA\n REASON FOR THIS EXAMINATION:\n hydronephrosis?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old female with metastatic breast cancer, increasing\n creatinine.\n\n COMPARISON: CT torso from .\n\n RENAL ULTRASOUND: Examination is suboptimal due to patient's body habitus.\n The right kidney measures 10.1 cm, and the left kidney measures 12.3 cm.\n There are no renal masses, stones, or hydronephrosis. No free fluid is\n identified. The bladder is partially distended with urine, and appears\n normal.\n\n IMPRESSION: Normal kidneys.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198613, "text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in empyema drainage\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with breast cancer, b/l empyemas s/p bilateral chest tubes\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in empyema drainage\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Breast cancer, bilateral empyemas, bilateral chest tubes\n placed, evaluate for change.\n\n The position of the chest tubes is unchanged. There are low lung volumes but\n there does appear to be better aeration of the left chest on this film\n compared to the prior film of .\n\n IMPRESSION: Poor aeration left lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198596, "text": " 11:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CT position, PTX\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman s/p VATS decort\n REASON FOR THIS EXAMINATION:\n CT position, PTX\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Chest tube placed, evaluate for pneumothorax.\n\n Two chest tubes have been placed on the right side. The tip of one lies at\n the apex, the other in the mid chest. A third tube is seen parallel to the\n right hemidiaphragm.\n\n There is increase in the hilar shadows probably post-surgical representing\n bleeding in this region. There is no pneumothorax seen.\n\n The position of the left chest tubes is unchanged.\n\n IMPRESSION: Two, probably three right chest tubes placed. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198148, "text": " 9:48 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: check CT placement\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with b/l empyema s/p left VATS decortication\n REASON FOR THIS EXAMINATION:\n check CT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: VATS decortication, for chest tube placement.\n\n FINDINGS: In comparison with study of of earlier in this date, there\n has been placement of a left chest tube with its tip in the medial apical\n region. No evidence of pneumothorax. Continued low lung volumes with\n bibasilar opacifications consistent with pleural effusion and compressive\n atelectasis. The left hemidiaphragm is more sharply seen than on the previous\n study.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-17 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1197589, "text": " 2:37 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: pulmonary effusion vs infiltrate;\n Admitting Diagnosis: PORT INFECTION\n Contrast: OPTIRAY Amt: 130CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with pleural effusions, hx breast ca; entercoccus and MSSA\n bacteremia\n REASON FOR THIS EXAMINATION:\n pulmonary effusion vs infiltrate;\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MLHh FRI 7:19 PM\n Mod bilat pleural effusions, L>R. Partially loculated w/ complex contents,\n suggesting malignant effusions. No consolidation. 5-mm RML nodule.\n Prominent thoracic LN to 13 mm.\n Large R lobe liver met, innumerable nodal mets in porta hepatis/peripancreatic\n regions, celiac axis, and retroperitoneum.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old female with stage IV breast cancer, port infection\n and MSSA bacteremia.\n\n COMPARISON: Chest radiograph from at 9:26.\n\n TECHNIQUE: Helical MDCT images were acquired through the torso with\n intravenous and oral contrast. 5-mm axial, coronal, and sagittal multiplanar\n reformats were generated.\n\n FINDINGS: Open surgical defect is present in the upper left breast, with\n internal gauze packing. There are no drainable fluid collections.\n\n Right subclavian catheter terminates in the mid SVC. Thoracic aorta and\n central pulmonary arteries are unremarkable. Heart size is at the upper\n limits of normal, without pericardial effusion. Coarse calcifications are\n noted in the left anterior descending and circumflex coronary arteries.\n\n Moderate bilateral pleural effusions are present, left greater than right.\n These demonstrate a partially loculated morphology, with internal attenuation\n of 30 Hounsfield units, suggestive of complex fluid/malignant effusion. There\n is adjacent compressive atelectasis. There is a 5-mm nodule in the right\n middle lobe (3:18).\n\n Multiple prominent intrathoracic lymph nodes are present, measuring 14 mm in\n the precarinal region, 8 mm in the right hilum, and 10 mm in the subcarinal\n region. There is no axillary or internal mammary adenopathy.\n\n ABDOMEN: A 10.7 x 8.7 cm hepatic mass is centered in segments V/VI, and\n infiltrates the majority of the right hepatic lobe. This demonstrates\n lobulated borders, multiple internal septations, heterogeneous\n hypoenhancement, and central areas of low attenuation suggestive of necrosis.\n There is encasement and attenuation of the right anterior and posterior portal\n (Over)\n\n 2:37 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: pulmonary effusion vs infiltrate;\n Admitting Diagnosis: PORT INFECTION\n Contrast: OPTIRAY Amt: 130CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n veins, though distal perfusion appears preserved. Numerous enlarged,\n heterogeneously hypoenhancing porta hepatis and peripancreatic nodes are\n present, measuring up to 4.8 x 3 cm. The gallbladder is partially collapsed,\n with mild circumferential wall edema that is likely reactive. The pancreas is\n atrophic and fatty replaced. There is no significant intra- or extra-hepatic\n biliary ductal dilation. Spleen is normal in size.\n\n The adrenals are normal. Kidneys enhance and excrete contrast promptly and\n symmetrically, without masses or hydronephrosis. 5-mm hypodensity in the left\n lower renal pole is too small to characterize, but likely represents a cyst.\n\n The stomach and small bowel are unremarkable.\n\n PELVIS: The appendix, colon, and rectum are normal. Bladder is collapsed and\n not well evaluated. Uterus and ovaries are unremarkable. Trace free fluid is\n present in the pelvis, within physiologic limits.\n\n Mesenteric lymph nodes are enlarged up to 10-13 mm, with partial encasement of\n the celiac axis, and also present at the root of the mesentery. There is\n massive conglomerate retroperitoneal lymphadenopathy, measuring up to 2.8 cm\n TV x 2.3 cm AP x 4.3 cm SI in the superior left paraaortic region, 4.6 cm TV x\n 2.3 cm AP x 8.4 cm SI in the inferior left paraaortic region, 2.2 x 1.5 and 2\n x 1.7 cm in the superior aortocaval region, and 2.6 cm TV x 1.2 cm AP x 3.8 cm\n SI in the inferior aortocaval region.\n\n The bones are diffusely demineralized, with moderate multilevel degenerative\n changes. No suspicious lytic or sclerotic osseous lesions are identified.\n\n IMPRESSION:\n 1. Bilateral moderate pleural effusions, likely malignant effusions.\n 2. 5-mm right middle lobe nodule and prominent intrathoracic lymph nodes.\n 2. Large right lobe hepatic metastasis and innumerable nodal metastases in\n the porta hepatis, mesentery, and retroperitoneum.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1197261, "text": " 10:00 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: SL R basilic 41cm PICC, thanks, \n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with new PICC\n REASON FOR THIS EXAMINATION:\n SL R basilic 41cm PICC, thanks, \n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: New PICC line.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n The current study demonstrates the placement of the PICC line tip being\n approximately 3 cm below the cavoatrial junction and should be pulled back.\n Lung volumes remain low. Bibasal atelectasis is re-demonstrated and there is\n most likely present small bilateral pleural effusion. There is no evidence of\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1198184, "text": " 11:10 AM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with b/l empyema s/p left VATS decortication\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left video-assisted thoracoscopic surgery with\n bilateral empyema. Please assess for progression.\n\n COMPARISONS: Multiple images spanning from to , the most\n recent one being a portable chest x-ray performed on .\n\n TECHNIQUE: PA and lateral chest x-ray.\n\n FINDINGS: A right-sided PICC line and a left-sided thoracostomy chest tube are\n in the proper position and unchanged since X-ray performed on at 10\n pm. The left costophrenic angle is discernible probably secondary to\n evacuation of left effusion. Lung volumes are low and there continues to be\n bibasilar atelectasis and right pleural effusion which are stable when\n compared to studies from after accounting for difference in\n techniques. No evidence of pneumothorax.\n\n IMPRESSION:\n 1. Interval improvement of left-sided pleural effusion.\n 2. Bibasilar opacification consistent with compressive atelectasis.\n 3. Cardiomediastinal contour and lung volumes are stable from prior exam.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-23 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1198371, "text": " 11:07 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PORT INFECTION\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with b/l pleural effusions, r side s/p tap, l side s/p vats\n w/ 2 chest tubes\n REASON FOR THIS EXAMINATION:\n pre-op eval of pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of pleural effusions after VATS.\n\n COMPARISON: Multiple radiographs, latest PA and lateral chest x-ray was from\n .\n\n TECHNIQUE: PA and lateral chest x-rays.\n\n FINDINGS: The chest radiograph is basically unchanged from prior exam\n allowing for difference in positioning of the patient and technique. The\n left-sided chest tube is stable in the left apex. Diminished bilateral lung\n volumes, cardiomegaly, and bilateral pleural effusions are stable from prior\n exam.\n\n IMPRESSION: No changes since prior chest x-ray in .\n\n" }, { "category": "Radiology", "chartdate": "2122-07-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1197375, "text": " 1:03 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with shortness of breath, wheeze, bacteremia, h/o breast ca\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath, to rule out chest infiltrates.\n\n TECHNIQUE: Chest x-ray, PA and lateral views acquired in sitting position.\n\n COMPARISON: Comparison was made to the prior study done on .\n\n FINDINGS:\n\n LINES AND TUBES: The tip of the right PICC line is seen to end at the\n junction of the SVC and right atrium.\n\n LUNGS: Both the lung volumes are low, which reduces the sensitivity and\n specificity for detection of the lung pathologies. Further, details were\n difficult to obtain because of the morbid obesity status.\n\n PLEURA: There is an interval blunting of the lateral and posterior pleural\n recess suggestive of an interval development of bilateral pleural effusions.\n No evidence of pneumothorax.\n\n MEDIASTINUM: Evaluation of cardiomediastinal silhouette is limited due to the\n portable technique.\n\n\n IMPRESSION:\n\n Interval development of bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1198049, "text": " 9:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: upright to eval pneumothorax\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with shortness of breath after right thoracentesis - upright\n please\n REASON FOR THIS EXAMINATION:\n upright to eval pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation for the pneumothorax post-thoracentesis.\n\n IMPRESSION\n\n A right-sided PICC line terminates in the distal SVC. Both lung volumes are\n low volume. There is interval improvement in the pulmonary edema. Bilateral\n pleural effusions are persisting and unchanged. There is an increased\n retrocardiac opacity suggestive of a left lower lobe collapse. The cardiac\n silhouette is difficult to evaluate due to the position and technique.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1197750, "text": " 7:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval evaluation after diuresis\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with metastatic breast cancer with dyspnea and new pleural\n effusions\n REASON FOR THIS EXAMINATION:\n ? interval evaluation after diuresis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic breast cancer, dyspnea, new effusions status post\n diuresis.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n There are low inspiratory volumes. Compared with , the CHF findings are\n similar, possibly slightly worse. There are bilateral effusions with left\n lower lobe collapse and/or consolidation. A right-sided PICC line is present,\n -- the tip is obscured, but probably lies near the SVC/RA junction.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1196857, "text": " 5:05 PM\n CHEST (PA & LAT) Clip # \n Reason: Acute CP process?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with L port infection.\n REASON FOR THIS EXAMINATION:\n Acute CP process?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: _____ infection, acute chest pain.\n\n CHEST (PA & LAT) No previous chest x-rays on PACS record for comparison.\n\n A left-sided catheter is present, tip over SVC/RA junction.\n\n There are low inspiratory volumes, limiting assessment of cardiomediastinal\n silhouette and vascular markings. Possibility of some patchy opacity in the\n lingula and left lower lobe cannot be excluded, though the appearance is\n likely accentuated by low inspiratory volumes. No CHF or effusion.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1197957, "text": " 3:28 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate pleural effusions/congestion\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with dyspnea\n REASON FOR THIS EXAMINATION:\n evaluate pleural effusions/congestion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old woman with dyspnea, evaluate pleural effusions or\n congestion.\n\n COMPARISON: Chest radiograph from .\n\n TWO VIEWS OF THE CHEST:\n\n The lungs are low in volume with moderate bilateral interstitial opacities\n that are improved compared to the prior examination. The cardiac silhouette\n is normal. The mediastinal silhouette and hilar contours are normal. Mild\n blunting in both costophrenic angles suggest small bilateral pleural effusion.\n A right-sided PICC line terminates in the distal SVC appropriately.\n\n IMPRESSION:\n\n Improved mild edema with small bilateral effusions.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-24 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1198494, "text": " 9:16 AM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: R/O upper extremity thrombosis\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with R arm swelling, PIC in place, increased swelling,\n tachycardia, and increased O2 requirement\n REASON FOR THIS EXAMINATION:\n R/O upper extremity thrombosis\n ______________________________________________________________________________\n WET READ: LMFn FRI 10:12 AM\n No right upper extremity DVT.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT UPPER EXTREMITY VASCULAR ULTRASOUND\n\n DATE: .\n\n COMPARISON: None.\n\n CLINICAL HISTORY: 51-year-old woman with right arm swelling, PICC in place,\n increased swelling, tachycardia and increased O2 requirement. Evaluate for\n upper extremity thrombosis.\n\n TECHNIQUE: Multiple son -scale images of the right upper\n extremity veins were obtained with comparison images of the left subclavian\n vein. Select images were supplemented with color Doppler and spectral\n waveform analysis.\n\n FINDINGS:\n\n The right upper extremity deep veins are patent and compressible with normal\n waveforms including the subclavian, internal jugular, axillary, brachials,\n basilic, and cephalic veins. Comparison to the left subclavian vein was\n obtained. The left subclavian vein is patent.\n\n IMPRESSION:\n\n No right upper extremity DVT.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-23 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1198432, "text": " 6:39 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? pulmonary effusion\n Admitting Diagnosis: PORT INFECTION\n Contrast: VISAPAQUE Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with metastatic breast cancer presenting with bilateral\n empyemas s/p VATS on left now acutely tachycardiac.\n REASON FOR THIS EXAMINATION:\n ? pulmonary effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:36 PM\n 1. Limited study from suboptimal IV bolus timing and body habitus. No central\n or lobar pulmonary embolism. No acute aortic pathology.\n 2. Mildly loculated, small R pleural effusion. Subtotal RLL atelectasis.\n Mild L basilar atelectasis. 6 mm known RML nodule.\n 3. Left chest tube in the L base. Tiny left PTX. (image 3:34).\n 4. Mediastinal lymphadenopathy.\n 5. Extensive liver mets and periportal lymphadenopathy.\n ______________________________________________________________________________\n FINAL REPORT\n CT THORAX\n\n INDICATION: 51-year-old female with metastatic breast cancer and bilateral\n empyema with effusions, now to rule out pulmonary embolism.\n\n TECHNIQUE: Contrast-enhanced CT of thorax was performed using our standard\n department protocol to evaluate pulmonary embolism. The opacification of the\n pulmonary arteries is inadequate rendering the study non-diagnostic for\n assessing pulmonary artery embolism. Comparison was made with prior CT torso\n study dated .\n\n FINDINGS:\n\n LINES AND TUBES: The right-sided PICC line terminates at the junction of SVC\n and right atrium.\n\n PULMONARY ARTERY: Opacification of pulmonary artery is inadequate rendering\n the study non-diagnostic for evaluation of pulmonary artery embolism. The\n main pulmonary artery proximal bifurcation measures 28.3 mm and is normal in\n caliber.\n\n AIRWAYS AND LUNGS: Bilateral lung volumes are low. There are two small\n non-calcified lung nodules measuring less than 4 mm in the right\n upper(3:42)and middle lobe (3:50). There are no other lung nodules or lesions\n which are of concern towards malignancy. There are two chest tube drains on\n the left side; one is extending high up to the apex and other one terminating\n at the lung base. There is an interval improvement in the left-sided pleural\n effusion with small residual loculated effusion. On the right side, the\n effusion is mild to moderate and has remained unchanged since .\n There is passive atelectasis of the underlying lung bilaterally. There is\n (Over)\n\n 6:39 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? pulmonary effusion\n Admitting Diagnosis: PORT INFECTION\n Contrast: VISAPAQUE Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n small pneumothorax on the left side anteriorly at the level of third rib.\n\n MEDIASTINUM: The thyroid gland is incompletely imaged and is grossly\n unremarkable. Heart is normal in size, and there is a trace pericardial\n effusion. Few small pockets of air are seen in the anterior pericardial fat in\n the vicinity of fractured anterior third rib. This should be correlated with\n recent regional interventional procedure in the thorax. Multiple small lymph\n nodes measuring < 10mm in short axis. For e.g. the lymph node in\n aorto-pulmonary window measures 8.5mm. There is no pathological enlargement of\n supraclavicular or axillary lymph node.\n\n ABDOMEN: The study is not tailored for the evaluation of the abdomen, but the\n limited views show a large heterogeneously hypodense lesion in the right lobe\n of liver approximately measuring 10.2 x 8.1cm which is incompletely imaged.\n This lesion was previously described as a metastasis in the abdomen CT dated\n . Multiple large retroperitoneal and porta hepatis lymph nodes are\n again seen which are incompletely imaged.\n\n BONES: There is fracture in the anterior end of the left third rib. No lytic\n or sclerotic bony lesions. Degenerative changes are seen at multiple\n vertebral levels.\n\n SOFT TISSUES: Surgical soft tissue defect with gauze packing seen in the left\n breast.\n\n IMPRESSION:\n\n The CT study is non-diagnostic for evaluation of the pulmonary artery\n embolism. If the clinical suspicion for PE persists, a repeat CT may be\n suggested. Alternatively, bilateral lower limb venous Doppler may be\n considered for initial further workup.\n\n Since - there is an interval decrease in left pleural effusion with\n persisting small loculated component and unchanged right mild-to-moderate\n effusion with passive atelectasis of the underlying lung.\n\n Two persistent small nodules measuring less than 4 mm, one in the right upper\n lobe and another in the right middle lobe.\n\n Large hetergeneously hypodense right liver lobe lesion previously\n characterized as a metastatisis; multiple mediastinal and enlarged\n retroperitoneal and porta hepatis lymph nodes, also concerning for potential\n metastases.\n\n Findings were discussed with Dr. at the time of dictation (10.00AM) on\n (Over)\n\n 6:39 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? pulmonary effusion\n Admitting Diagnosis: PORT INFECTION\n Contrast: VISAPAQUE Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n -14 .\n\n" }, { "category": "Radiology", "chartdate": "2122-07-20 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1197952, "text": " 3:03 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ?PE EVAL FOR DVT\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with hx stage IV breast ca metastatic to liver p/w worsening\n locculated bilateral pleural effusions, dyspnea and tachycardia.\n REASON FOR THIS EXAMINATION:\n ? evaluate for DVT\n ______________________________________________________________________________\n WET READ: LMFn MON 4:53 PM\n 1. No left lower extremity DVT.\n 2. No right lower extremity DVT.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VASCULAR ULTRASOUND\n\n COMPARISON: None.\n\n CLINICAL HISTORY: 51-year-old woman with history of stage IV breast cancer\n metastatic to the liver presents with worsening bilateral pleural effusion,\n dyspnea and tachycardia. Evaluate for DVT.\n\n TECHNIQUE: Multiple son -scale images of bilateral lower\n extremity vessels were obtained. Selected images were supplemented with color\n Doppler and special wave form analysis. When appropriate, images were\n augmented.\n\n FINDINGS: There is no right lower extremity DVT. The veins are patent and\n compressible with normal wave forms including the common femoral vein,\n superficial femoral vein, popliteal, posterior tibial and peroneal veins.\n\n There is no deep venous thrombosis on the left lower extremity. The venous\n structures are patent and compressible including the common femoral,\n superficial femoral, popliteal, posterior tibial and peroneal veins.\n\n IMPRESSION:\n 1. No left lower extremity DVT.\n 2. No right lower extremity DVT.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1197520, "text": " 9:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: etiology\n Admitting Diagnosis: PORT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with dyspnea, h/o breast ca\n REASON FOR THIS EXAMINATION:\n etiology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old female with history of breast cancer and dyspnea.\n\n COMPARISON: .\n\n PORTABLE UPRIGHT VIEW OF THE CHEST: Lung volumes are low. A right-sided PICC\n terminates at the cavoatrial junction. Bibasilar pleural effusions persist.\n There is opacification in the left lower lobe, likely collapse. The cardiac\n silhouette is difficult to evaluate. There is mild vascular congestion but no\n overt pulmonary edema.\n\n IMPRESSION: Bilateral pleural effusions and left lower lobe collapse.\n\n" }, { "category": "Echo", "chartdate": "2122-07-21 00:00:00.000", "description": "Report", "row_id": 92575, "text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Endocarditis. Left ventricular function. Shortness of breath.\nStatus: Inpatient\nDate/Time: at 21:11\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nAsked to perform TEE in patient with persistent fevers to r/o vegetations\n\nNo atrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. Regional left ventricular wall motion\nis normal. Overall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal. The ascending,\ntransverse and descending thoracic aorta are normal in diameter and free of\natherosclerotic plaque. The aortic valve leaflets (3) are mildly thickened. No\nmasses or vegetations are seen on the aortic valve. Trace aortic regurgitation\nis seen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. No mass or vegetation is seen on the mitral valve. There is no\npericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2122-07-20 00:00:00.000", "description": "Report", "row_id": 92576, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluation for endocarditis/persistant low grade fevers.\nHeight: (in) 61\nWeight (lb): 230\nBSA (m2): 2.01 m2\nBP (mm Hg): 106/67\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 10:22\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. No TS. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No vegetation/mass on pulmonic valve. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\ndiameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No masses or vegetations are seen on the aortic valve. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. No mass or vegetation is seen on the mitral\nvalve. Trivial mitral regurgitation is seen. The pulmonary artery systolic\npressure could not be determined. No vegetation/mass is seen on the pulmonic\nvalve. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2122-07-23 00:00:00.000", "description": "Report", "row_id": 256096, "text": "Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous\ntracing of heart rate has significantly increased.\n\n" }, { "category": "ECG", "chartdate": "2122-07-20 00:00:00.000", "description": "Report", "row_id": 256097, "text": "Normal sinus rhythm. Compared to tracing #1 no diagnostic interval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2122-07-20 00:00:00.000", "description": "Report", "row_id": 256098, "text": "Normal sinus rhythm. Low voltage in the lateral precordial leads. Poor R wave\nprogression. Compared to the previous tracing of , except for slowing of\nthe pulse rate, no diagnostic interval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2122-07-15 00:00:00.000", "description": "Report", "row_id": 256099, "text": "Sinus tachycardia. Possible left atrial abnormality. Diffuse ST-T wave\nchanges which are non-specific. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2182-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 437679, "text": "51 yo F with PMHx of etoh/cirrhosis and chronic pancreatitis who is\n actively abuse alcohol, tobacco, and opiates. Presented to ED this AM\n with intoxication and hematemesis. Reports being at \n earlier this week where she was transfused. She does not endorse\n active bleeding around that time. This AM, felt nauseated, went the\n bathroom and vomitted large amount of BRB. EMS called and reported\n several more episodes of hematemesis in the interim.\n In the ED, received 1L NS and a banana bag. IV Cipro, IV Protonix, GI\n consulted. Started on octreotide gtt.\n Events: On arrival to MICU CIWA 7- pt very talkative/slightly slurred\n speech consistently asking for pain medications. Hemodynamically\n stable- Hr 90\ns, BP stable 100-120\ns/, no N/V. Bedside endoscopy-\n sedated w/ total 4mg IV Midaz, 150mcg IV Fentanyl- 4 varicies banded.\n Needs social/addictions follow up.\n .H/O pancreatitis, chronic\n Assessment:\n soft rounded distended abd, c/o10/10 pain @ rest > pain w/\n palpation- mild increase in HR w/ palpation\n Action:\n 2mg IVP Morphine pre procedure, pt easily distracted about abd and\n engaging in conversation-then intermittently\nyou haven\nt given me pain\n medication-if you \nll just leave the hospital\n given total\n 150mcg Fentanyl during endoscpy\n Response:\n will not rate on numeric scale-\nunless you treat me- its just the worst\n pain\n Plan:\n IVF post bolus, counseling on pancreatitis, monitor lab trends, NPO\n Alcohol abuse\n Assessment:\n pt breath smells of alcohol, appears intoxicated on arrival w/ serum\n alcohol level 351- given total 20mg IVP Diazepam in ED, CIWA initially\n 7- trending up to 15, HCt dropping to 25 on recheck\n Action:\n CIWA- treating w/ 2mg IV Ativan for CIWA >10, bedside endoscopy w/ 4\n varicies banded, pt transfused 1 unit RBC for falling HCt- awaiting\n 2^nd unit\n Response:\n awaiting 2^nd unit-then serial Hct\n Plan:\n cont CIWA, transfusion as needed, addiction and social work consult in\n AM\n" }, { "category": "Physician ", "chartdate": "2182-01-10 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 437695, "text": "Chief Complaint: Hematemesis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 51 yo F with PMHx of etoh/cirrhosis and chronic pancreatitis who is\n actively abuse alcohol, tobacco, and opiates. Presented to ED this AM\n with intoxication and hematemesis. Reports being at \n earlier this week where she was transfused. She does not endorse\n active bleeding around that time. This AM, felt nauseated, went the\n bathroom and vomitted large amount of BRB. EMS called and reported\n several more episodes of hematemesis in the interim.\n In the ED, received 1L NS and a banana bag. GI consulted. Started on\n octreotide.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Unspecified \n Last dose of Antibiotics:\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Lasix, spironolactone, lactulose, omeprazole, advair, MVI, Folate,\n thiamine, pancreatic enzymes, morphine, ambien, albuterol PRN\n Past medical history:\n Family history:\n Social History:\n Cirrhosis/etoh\n chronic pancreatitis\n Tobacco abuse\n s/p hysterectomy\n NC\n Occupation: Former RN\n Drugs: Uses po opiates, reports using IV heroin for the first time last\n nigh\n Tobacco: Smokes 1ppd\n Alcohol: Drinks vodka regularly. Reports last drink was 5th of vodka\n on Tuesday night.\n Other: Lives alone.\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Genitourinary: No(t) Dysuria\n Flowsheet Data as of 04:37 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 98 (98 - 101) bpm\n BP: 109/67(76) {109/63(76) - 122/67(78)} mmHg\n RR: 25 (17 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 347 mL\n PO:\n TF:\n IVF:\n 347 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 347 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Smells of alcohol\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic), Borderline tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezes : Scattered B/L.)\n Abdominal: Soft, Bowel sounds present, Tender: RUQ/epigastric\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 104\n 30\n 108\n 0.7\n 9\n 28\n 105\n 3.6\n 144\n 6.8\n [image002.jpg]\n Other labs: PT / PTT / INR:16.8/34.6/1.5, ALT / AST:22/67, Alk Phos / T\n Bili:102/1.8, Amylase / Lipase:/79, Differential-Neuts:49, Lymph:38,\n Mono:7, Eos:4.7, Albumin:3.7\n Fluid analysis / Other labs: Ethanol 351\n U/A: Neg for infection\n Utox pos for benzos and opiates\n Imaging: CXR: Mildly reduced lung volumes. No infiltrate/effusions\n Microbiology: UCx: pending\n Assessment and Plan\n 51 yo compensated etoh/cirrhosis and active etoh/opiate abuse\n presenting with hematemesis with stable hemodynamics.\n GIB: Appears Upper. DDx includes variceal, MW tear, gastritis, PUD.\n NGT placement attempted in ED unsuccessfully, patient adamantly\n refusing one now.\n -Currently has 2 18 gauge IV's and a 20\n -GI to perform endoscopy tonight.\n -Will check serial HCT's Q6hr, transfuse to keep HCT >25\n -Octreotide gtt and IV PPI for now.\n -Low threshold for more IVF.\n -Trial of Vitamin K.\n -SBP prophylaxis with ciprofloxacin\n Etoh abuse: Per reports, has had a history of DT's in the past\n -CIWA scale\n -Vitamin Support\n -Once acute issues resolved, addiction consult\n Chronic pain: Will try to limit opiate use given her self reported\n addiction.\n Cirrhosis: Holding lasix and spironolactone for now.\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 02:55 PM\n 18 Gauge - 02:57 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 51 yo F with etoh and opiate abuse, cirrhosis, chronic pancreatitis who\n presented intoxicated with hematemesis. Apparently transfused earlier\n this week at . This morning she vomitted a large amount\n of BRB. EMS called and reported several more episodes of hematemesis\n in the interim. In the ED, given IVF with thiamine and folate and\n started on octreotide.\n Exam notable for Tm afebrile HR 98 BP 109/67 RR 18 with 99 sat\n on 2LPM\n No acute distress\n PERRL\n Normocephalic, Poor dentition\n RRR, no murmur\n Lungs with scattered wheezes\n Abdomen mild epigastric and RUQ tenderness\n Trace edema\n No jaundice\n Oriented x 3\n Labs notable for WBC 7K, HCT 30, plt 104 , Na 144 ,K+ 3.6 , HCO3 28\n ,Cr .7 , INR 1.5, TBili 1.8, albumin 3.7, EtOH 351, urine pos opiates\n and benzos, lipase 79\n Imaging: CXR low lung volumes, clear\n Problems: GI bleed, cirrhosis, EtOH intoxication, benzo and opiate\n abuse,\n Agree with plan to maintain adequate IV access, endoscopy tonight,\n serial HCT's Q6hr, transfuse to keep HCT >25, octreotide gtt and IV PPI\n for now, Vitamin K, SBP prophylaxis with ciprofloxacin, CIWA scale,\n folate + thiamine, limit opiate use given her self reported addiction,\n hold lasix and spironolactone.\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 35 min\n" }, { "category": "Nursing", "chartdate": "2182-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 437738, "text": "51 yo F with PMHx of etoh/cirrhosis and chronic pancreatitis who is\n actively abuse alcohol, tobacco, and opiates. Presented to ED this AM\n with intoxication and hematemesis. Reports being at \n earlier this week where she was transfused. She does not endorse\n active bleeding around that time. This AM, felt nauseated, went the\n bathroom and vomitted large amount of BRB. EMS called and reported\n several more episodes of hematemesis in the interim.\n In the ED, received 1L NS and a banana bag. IV Cipro, IV Protonix, GI\n consulted. Started on octreotide gtt.\n Events: On arrival to MICU CIWA 7- pt very talkative/slightly slurred\n speech consistently asking for pain medications. Hemodynamically\n stable- Hr 90\ns, BP stable 100-120\ns/, no N/V. Bedside endoscopy-\n sedated w/ total 4mg IV Midaz, 150mcg IV Fentanyl- 4 varicies banded.\n Needs social/addictions follow up.\n .H/O pancreatitis, chronic\n Assessment:\n post endoscopy pt yelling and screaming that she was having severe\n abdominal pain and needed pain medication. Pt wretching and vomiting\n lrg amt\ns of clear fluid streaked with blood. Strong smell of alcohol\n from the emesis.\n Action:\n pt medicated with morhphine 2-4mg ivp and Ativan 1-2mg ivp according to\n ciwa scale.\n Response:\n pt responded well to pain and Ativan and able to sleep.\n Plan:\n cont to med as needed. Follow hct\n Alcohol abuse\n Assessment:\n pt very agitated when experiencing abdominal pain. Eventually will\n start vomiting bilious material. Does not tolerate waiting any length\n of time for next dose of pain. Med. As soon as pt wakes she starts\n coughing and throwing up.\n Action:\n cont to follow ciwa scale for medication.\n Response:\n med as needed for comfort\n Plan:\n need social work consult. Possible c/o\n" }, { "category": "Nursing", "chartdate": "2182-01-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 437864, "text": "51 yo F with PMHx of etoh/cirrhosis and chronic pancreatitis who is\n actively abuse alcohol, tobacco, and opiates. Presented to ED this AM\n with intoxication and hematemesis. Reports being at \n earlier this week where she was transfused. She does not endorse\n active bleeding around that time. This AM, felt nauseated, went the\n bathroom and vomitted large amount of BRB. EMS called and reported\n several more episodes of hematemesis in the interim.\n In the ED, received 1L NS and a banana bag. IV Cipro, IV Protonix, GI\n consulted. Started on octreotide gtt.\n Events: On arrival to MICU CIWA 7- pt very talkative/slightly slurred\n speech consistently asking for pain medications. Hemodynamically\n stable- Hr 90\ns, BP stable 100-120\ns/, no N/V. Bedside endoscopy-\n sedated w/ total 4mg IV Midaz, 150mcg IV Fentanyl- 4 varicies banded.\n Needs social/addictions follow up.\n .H/O pancreatitis, chronic\n Assessment:\n night RN - Pt. occasionally waking, yelling out that she is in pain\n if no one enters her room quickly she will put a finger down her\n throat to induce vomiting in an attempt to obtain pain, sedation or\n anti-nausea meds. Vomitus is clear to dry retching. If retching enough\n will induce streaks of blood in clear. Received 2 units PRBC overnight\n for Hct 25\n appropriate increase to 33.5.\n Action:\n No periods of agitation or screaming this AM. No vomiting. Sleeping\n most of morning\n thought to be related to Lactulose being held as\n patient has been NPO\n pt. takes Lactulose at home for cirrhosis.\n Response:\n Starting clear liquids\n if no emesis occurs will restart Lactulose.\n Hct stable at noon - 33\n Plan:\n Check Hct q8h. Transfuse appropriately, ativan per CIWA scale, morphine\n for chronic abdominal pain. Restart Lactulose.\n Alcohol abuse\n Assessment:\n Pt. lethargic but arousable to voice this AM. Lactulose held as patient\n has been NPO. No further bleeding s/p banding. Transfused 2 units last\n PM. Hct bumped appropriately.\n Action:\n cont to follow ciwa scale for medication.\n Response:\n med as needed for comfort\n Plan:\n need social work consult.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n Admission weight:\n 76.2 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unspecified \n Precautions:\n PMH: Asthma, ETOH\n CV-PMH:\n Additional history: alcoholic cirrhosis- ETOH abuse w/ ? Hx Dt's,\n chronic pancreatitis, asthma, uterine and cervical CA s/p hysterectomy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:134\n D:80\n Temperature:\n 97.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 97 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 4,470 mL\n 24h total out:\n 3,475 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:26 AM\n Potassium:\n 3.9 mEq/L\n 04:26 AM\n Chloride:\n 106 mEq/L\n 04:26 AM\n CO2:\n 21 mEq/L\n 04:26 AM\n BUN:\n 7 mg/dL\n 04:26 AM\n Creatinine:\n 0.7 mg/dL\n 04:26 AM\n Glucose:\n 118 mg/dL\n 04:26 AM\n Hematocrit:\n 33.7 %\n 11:44 AM\n Finger Stick Glucose:\n 161\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7\n Transferred to: 10\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2182-01-10 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 437617, "text": "Chief Complaint: Hematemesis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 51 yo F with PMHx of etoh/cirrhosis and chronic pancreatitis who is\n actively abuse alcohol, tobacco, and opiates. Presented to ED this AM\n with intoxication and hematemesis. Reports being at \n earlier this week where she was transfused. She does not endorse\n active bleeding around that time. This AM, felt nauseated, went the\n bathroom and vomitted large amount of BRB. EMS called and reported\n several more episodes of hematemesis in the interim.\n In the ED, received 1L NS and a banana bag. GI consulted. Started on\n octreotide.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Penicillins\n Unspecified \n Last dose of Antibiotics:\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Lasix, spironolactone, lactulose, omeprazole, advair, MVI, Folate,\n thiamine, pancreatic enzymes, morphine, ambien, albuterol PRN\n Past medical history:\n Family history:\n Social History:\n Cirrhosis/etoh\n chronic pancreatitis\n Tobacco abuse\n s/p hysterectomy\n NC\n Occupation: Former RN\n Drugs: Uses po opiates, reports using IV heroin for the first time last\n nigh\n Tobacco: Smokes 1ppd\n Alcohol: Drinks vodka regularly. Reports last drink was 5th of vodka\n on Tuesday night.\n Other: Lives alone.\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: Abdominal pain, Nausea, Emesis\n Genitourinary: No(t) Dysuria\n Flowsheet Data as of 04:37 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 98 (98 - 101) bpm\n BP: 109/67(76) {109/63(76) - 122/67(78)} mmHg\n RR: 25 (17 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 347 mL\n PO:\n TF:\n IVF:\n 347 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 347 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Smells of alcohol\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic), Borderline tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezes : Scattered B/L.)\n Abdominal: Soft, Bowel sounds present, Tender: RUQ/epigastric\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 104\n 30\n 108\n 0.7\n 9\n 28\n 105\n 3.6\n 144\n 6.8\n [image002.jpg]\n Other labs: PT / PTT / INR:16.8/34.6/1.5, ALT / AST:22/67, Alk Phos / T\n Bili:102/1.8, Amylase / Lipase:/79, Differential-Neuts:49, Lymph:38,\n Mono:7, Eos:4.7, Albumin:3.7\n Fluid analysis / Other labs: Ethanol 351\n U/A: Neg for infection\n Utox pos for benzos and opiates\n Imaging: CXR: Mildly reduced lung volumes. No infiltrate/effusions\n Microbiology: UCx: pending\n Assessment and Plan\n 51 yo compensated etoh/cirrhosis and active etoh/opiate abuse\n presenting with hematemesis with stable hemodynamics.\n GIB: Appears Upper. DDx includes variceal, MW tear, gastritis, PUD.\n NGT placement attempted in ED unsuccessfully, patient adamantly\n refusing one now.\n -Currently has 2 18 gauge IV's and a 20\n -GI to perform endoscopy tonight.\n -Will check serial HCT's Q6hr, transfuse to keep HCT >25\n -Octreotide gtt and IV PPI for now.\n -Low threshold for more IVF.\n -Trial of Vitamin K.\n -SBP prophylaxis with ciprofloxacin\n Etoh abuse: Per reports, has had a history of DT's in the past\n -CIWA scale\n -Vitamin Support\n -Once acute issues resolved, addiction consult\n Chronic pain: Will try to limit opiate use given her self reported\n addiction.\n Cirrhosis: Holding lasix and spironolactone for now.\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 02:55 PM\n 18 Gauge - 02:57 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2182-01-11 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 437844, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Admitted to the ICU yesterday from the ED with\n intoxication/hematemesis. Underwent endoscopy in the ICU by\n GI-->revealed evidence of recent variceal bleeding-->4 varices banded.\n Received 2 units of PRBC overnight.\n History obtained from Medical records\n Allergies:\n Penicillins\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 12:17 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 07:20 PM\n Midazolam (Versed) - 07:28 PM\n Pantoprazole (Protonix) - 12:17 AM\n Carafate (Sucralfate) - 12:17 AM\n Lorazepam (Ativan) - 04:31 AM\n Morphine Sulfate - 05:44 AM\n Other medications:\n Thiamine, Folate, MVI, RISS, sucralfate\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.9\nC (96.7\n HR: 92 (86 - 113) bpm\n BP: 136/58(77) {90/44(55) - 146/110(114)} mmHg\n RR: 23 (14 - 25) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,687 mL\n 2,621 mL\n PO:\n TF:\n IVF:\n 3,987 mL\n 2,621 mL\n Blood products:\n 700 mL\n Total out:\n 400 mL\n 2,450 mL\n Urine:\n 400 mL\n 1,950 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 4,287 mL\n 171 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress, No(t) Anxious, Appears older\n than stated age, sleepy\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic), Tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), Poor insp effort\n Abdominal: Soft, Bowel sounds present, No(t) Distended, Tender:\n RUQ/epigastric\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.7 g/dL\n 65 K/uL\n 118 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 106 mEq/L\n 139 mEq/L\n 33.5 %\n 4.1 K/uL\n [image002.jpg]\n 04:36 PM\n 04:26 AM\n WBC\n 4.1\n Hct\n 25.8\n 33.5\n Plt\n 65\n Cr\n 0.7\n Glucose\n 118\n Other labs: PT / PTT / INR:17.4/35.8/1.6, Ca++:7.7 mg/dL, Mg++:1.4\n mg/dL, PO4:2.8 mg/dL\n Imaging: No new imaging today\n Microbiology: UCx: Pending\n Assessment and Plan\n 51 yo compensated etoh/cirrhosis and active etoh/opiate abuse\n presenting with hematemesis with stable hemodynamics.\n GIB: Appears Variceal. No evidence of active bleeding at present.\n -Currently has 2 18 gauge IV's and a 20\n -Will check HCT Q8hr today and space out if stable.\n -Octreotide gtt and IV PPI for now per GI.\n -SBP prophylaxis with ciprofloxacin\n Etoh abuse: Per reports, has had a history of DT's in the past\n -CIWA scale\n -Vitamin Support\n -Addiction consult\n Chronic pain: Will try to limit opiate use given her self reported\n addiction.\n Cirrhosis: Holding lasix and spironolactone for now.\n -Restart lactulose\n FEN: Clears today.\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:55 PM\n 18 Gauge - 02:57 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2182-01-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 437846, "text": "Chief Complaint:\n 24 Hour Events:\n EGD\n 4 bands banded\n BP stable\n N/V\n Allergies:\n Penicillins\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 12:17 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 07:20 PM\n Midazolam (Versed) - 07:28 PM\n Pantoprazole (Protonix) - 12:17 AM\n Carafate (Sucralfate) - 12:17 AM\n Lorazepam (Ativan) - 04:31 AM\n Morphine Sulfate - 05:44 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.9\nC (96.7\n HR: 107 (86 - 113) bpm\n BP: 139/81(94) {90/44(55) - 146/110(114)} mmHg\n RR: 22 (14 - 25) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,687 mL\n 1,800 mL\n PO:\n TF:\n IVF:\n 3,987 mL\n 1,800 mL\n Blood products:\n 700 mL\n Total out:\n 400 mL\n 2,000 mL\n Urine:\n 400 mL\n 1,500 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 4,287 mL\n -200 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n GEN: alert\n LUNGS: decr BS bibasilarly\n HEART: RRR, nl S!S2, no m/r/g\n ABD: soft, diffusely tender\n EXT: NO edema\n Labs / Radiology\n 65 K/uL\n 11.7 g/dL\n 118 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 106 mEq/L\n 139 mEq/L\n 33.5 %\n 4.1 K/uL\n [image002.jpg]\n 04:36 PM\n 04:26 AM\n WBC\n 4.1\n Hct\n 25.8\n 33.5\n Plt\n 65\n Cr\n 0.7\n Glucose\n 118\n Other labs: PT / PTT / INR:17.4/35.8/1.6, Ca++:7.7 mg/dL, Mg++:1.4\n mg/dL, PO4:2.8 mg/dL\n Imaging: CXR :\n IMPRESSION: No pneumonia or congestive heart failure.\n Microbiology: Urine : no growth to date\n Assessment and Plan\n This 51F with alcoholic cirrhosis presents with hematemesis.\n # Hematemesis: EGD revealed 4 varices, stigmata of recent bleeding, s/p\n banding.\n - s/p 2 units prbcs on \n - follow Hct q6\n - transfuse to Hct > 25\n - PIV x3\n - T+S\n - Sucralfate\n - IV protonix, octreotide drip\n - vitamin K 5mg was given x1: no improvement in INR\n - Liver recs: can start her on clears, but still N/V\n # Abd pain: Has history of chronic pancreatitis. Lipase mildly\n elevated. No need for imaging currently.\n - NPO\n - IVFs @ 200cc/hr\n - pain control\n # EtoH abuse\n - monitor per CIWA, ativan prn\n - MVT/thiamine/folate (banana bag daily\n - social work/ consult in AM\n # Anemia and thrombocytopenia Hct with appropriate bump from 2 units\n PRBCs. Plts down but likely consumption and now close to baseline\n - Trend Plt/Hct with transfusion plans as above\n # Alcoholic cirrhosis: Liver u/s consistent with cirrhosis but\n no evidence portal htn. AST/ALT >2 c/w EtoH\n - prophylactic cipro 400mg IV BID x 3 days ()\n - hold lasix and spironolactone in setting of bleed\n - hold lactulose while NPO\n #. Asthma\n - Continue home inhalers\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:55 PM\n 18 Gauge - 02:57 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2182-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 437620, "text": "Events:\n" }, { "category": "Nursing", "chartdate": "2182-01-11 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 437833, "text": "51 yo F with PMHx of etoh/cirrhosis and chronic pancreatitis who is\n actively abuse alcohol, tobacco, and opiates. Presented to ED this AM\n with intoxication and hematemesis. Reports being at \n earlier this week where she was transfused. She does not endorse\n active bleeding around that time. This AM, felt nauseated, went the\n bathroom and vomitted large amount of BRB. EMS called and reported\n several more episodes of hematemesis in the interim.\n In the ED, received 1L NS and a banana bag. IV Cipro, IV Protonix, GI\n consulted. Started on octreotide gtt.\n Events: On arrival to MICU CIWA 7- pt very talkative/slightly slurred\n speech consistently asking for pain medications. Hemodynamically\n stable- Hr 90\ns, BP stable 100-120\ns/, no N/V. Bedside endoscopy-\n sedated w/ total 4mg IV Midaz, 150mcg IV Fentanyl- 4 varicies banded.\n Needs social/addictions follow up.\n .H/O pancreatitis, chronic\n Assessment:\n night RN - Pt. occasionally waking, yelling out that she is in pain\n if no one enters her room quickly she will put a finger down her\n throat to induce vomiting in an attempt to obtain pain, sedation or\n anti-nausea meds. Vomitus is clear to dry retching. If retching enough\n will induce streaks of blood in clear. Received 2 units PRBC overnight\n for Hct 25\n appropriate increase to 33.5.\n Action:\n No periods of agitation or screaming this AM. No vomiting. Sleeping\n most of morning\n thought to be related to Lactulose being held as\n patient has been NPO\n pt. takes Lactulose at home for cirrhosis.\n Response:\n Starting clear liquids\n if no emesis occurs will restart Lactulose.\n Plan:\n Check Hct q8h. Transfuse appropriately, ativan per CIWA scale, morphine\n for chronic abdominal pain.\n Alcohol abuse\n Assessment:\n Pt. lethargic but arousable to voice this AM. Lactulose held as patient\n has been NPO. No further bleeding s/p banding. Transfused 2 units last\n PM. Hct bumped appropriately.\n Action:\n cont to follow ciwa scale for medication.\n Response:\n med as needed for comfort\n Plan:\n need social work consult.\n" }, { "category": "Nursing", "chartdate": "2182-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 437671, "text": "51 yo F with PMHx of etoh/cirrhosis and chronic pancreatitis who is\n actively abuse alcohol, tobacco, and opiates. Presented to ED this AM\n with intoxication and hematemesis. Reports being at \n earlier this week where she was transfused. She does not endorse\n active bleeding around that time. This AM, felt nauseated, went the\n bathroom and vomitted large amount of BRB. EMS called and reported\n several more episodes of hematemesis in the interim.\n In the ED, received 1L NS and a banana bag. IV Cipro, IV Protonix, GI\n consulted. Started on octreotide gtt.\n Events: On arrival to MICU CIWA 7- pt very talkative/slightly slurred\n speech consistently asking for pain medications. Hemodynamically\n stable- Hr 90\ns, BP stable 100-120\ns/, no N/V. Bedside endoscopy-\n sedated w/ total 4mg IV Midaz, 150mcg IV Fentanyl- 4 varicies banded.\n Needs social/addictions follow up.\n .H/O pancreatitis, chronic\n Assessment:\n soft rounded distended abd, c/o10/10 pain @ rest > pain w/\n palpation- mild increase in HR w/ palpation\n Action:\n 2mg IVP Morphine pre procedure, pt easily distracted about abd and\n engaging in conversation-then intermittently\nyou haven\nt given me pain\n medication-if you \nll just leave the hospital\n given total\n 150mcg Fentanyl during endoscpy\n Response:\n will not rate on numeric scale-\nunless you treat me- its just the worst\n pain\n Plan:\n IVF post bolus, counseling on pancreatitis, monitor lab trends, NPO\n Alcohol abuse\n Assessment:\n pt breath smells of alcohol, appears intoxicated on arrival w/ serum\n alcohol level 351- given total 20mg IVP Diazepam in ED, CIWA initially\n 7- trending up to 15, HCt dropping to 25 on recheck\n Action:\n CIWA- treating w/ 2mg IV Ativan for CIWA >10, bedside endoscopy w/ 4\n varicies banded, pt transfused 1 unit RBC for falling HCt- awaiting\n 2^nd unit\n Response:\n awaiting 2^nd unit-then serial Hct\n Plan:\n cont CIWA, transfusion as needed, addiction and social work consult in\n AM\n" }, { "category": "Physician ", "chartdate": "2182-01-11 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 437818, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Admitted to the ICU yesterday from the ED with\n intoxication/hematemesis. Underwent endoscopy in the ICU by\n GI-->revealed evidence of recent variceal bleeding-->4 varices banded.\n Received 2 units of PRBC overnight.\n History obtained from Medical records\n Allergies:\n Penicillins\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 12:17 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 07:20 PM\n Midazolam (Versed) - 07:28 PM\n Pantoprazole (Protonix) - 12:17 AM\n Carafate (Sucralfate) - 12:17 AM\n Lorazepam (Ativan) - 04:31 AM\n Morphine Sulfate - 05:44 AM\n Other medications:\n Thiamine, Folate, MVI, RISS, sucralfate\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.9\nC (96.7\n HR: 92 (86 - 113) bpm\n BP: 136/58(77) {90/44(55) - 146/110(114)} mmHg\n RR: 23 (14 - 25) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,687 mL\n 2,621 mL\n PO:\n TF:\n IVF:\n 3,987 mL\n 2,621 mL\n Blood products:\n 700 mL\n Total out:\n 400 mL\n 2,450 mL\n Urine:\n 400 mL\n 1,950 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 4,287 mL\n 171 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress, No(t) Anxious, Appears older\n than stated age, sleepy\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic), Tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), Poor insp effort\n Abdominal: Soft, Bowel sounds present, No(t) Distended, Tender:\n RUQ/epigastric\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.7 g/dL\n 65 K/uL\n 118 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 106 mEq/L\n 139 mEq/L\n 33.5 %\n 4.1 K/uL\n [image002.jpg]\n 04:36 PM\n 04:26 AM\n WBC\n 4.1\n Hct\n 25.8\n 33.5\n Plt\n 65\n Cr\n 0.7\n Glucose\n 118\n Other labs: PT / PTT / INR:17.4/35.8/1.6, Ca++:7.7 mg/dL, Mg++:1.4\n mg/dL, PO4:2.8 mg/dL\n Imaging: No new imaging today\n Microbiology: UCx: Pending\n Assessment and Plan\n 51 yo compensated etoh/cirrhosis and active etoh/opiate abuse\n presenting with hematemesis with stable hemodynamics.\n GIB: Appears Variceal. No evidence of active bleeding at present.\n -Currently has 2 18 gauge IV's and a 20\n -Will check HCT Q8hr today and space out if stable.\n -Octreotide gtt and IV PPI for now per GI.\n -SBP prophylaxis with ciprofloxacin\n Etoh abuse: Per reports, has had a history of DT's in the past\n -CIWA scale\n -Vitamin Support\n -Addiction consult\n Chronic pain: Will try to limit opiate use given her self reported\n addiction.\n Cirrhosis: Holding lasix and spironolactone for now.\n -Restart lactulose\n FEN: Clears today.\n Rest of plan per Resident Note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:55 PM\n 18 Gauge - 02:57 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2182-01-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 437784, "text": "Chief Complaint:\n 24 Hour Events:\n EGD\n 4 bands banded\n BP stable\n N/V\n Allergies:\n Penicillins\n Unspecified \n Last dose of Antibiotics:\n Ciprofloxacin - 12:17 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Fentanyl - 07:20 PM\n Midazolam (Versed) - 07:28 PM\n Pantoprazole (Protonix) - 12:17 AM\n Carafate (Sucralfate) - 12:17 AM\n Lorazepam (Ativan) - 04:31 AM\n Morphine Sulfate - 05:44 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.9\nC (96.7\n HR: 107 (86 - 113) bpm\n BP: 139/81(94) {90/44(55) - 146/110(114)} mmHg\n RR: 22 (14 - 25) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,687 mL\n 1,800 mL\n PO:\n TF:\n IVF:\n 3,987 mL\n 1,800 mL\n Blood products:\n 700 mL\n Total out:\n 400 mL\n 2,000 mL\n Urine:\n 400 mL\n 1,500 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 4,287 mL\n -200 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 65 K/uL\n 11.7 g/dL\n 118 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 7 mg/dL\n 106 mEq/L\n 139 mEq/L\n 33.5 %\n 4.1 K/uL\n [image002.jpg]\n 04:36 PM\n 04:26 AM\n WBC\n 4.1\n Hct\n 25.8\n 33.5\n Plt\n 65\n Cr\n 0.7\n Glucose\n 118\n Other labs: PT / PTT / INR:17.4/35.8/1.6, Ca++:7.7 mg/dL, Mg++:1.4\n mg/dL, PO4:2.8 mg/dL\n Imaging: CXR :\n IMPRESSION: No pneumonia or congestive heart failure.\n Microbiology: Urine : no growth to date\n Assessment and Plan\n This 51F with alcoholic cirrhosis presents with hematemesis.\n # Hematemesis: EGD revealed 4 varices, stigmata of recent bleeding, s/p\n banding.\n - s/p 2 units prbcs on \n - follow Hct q6\n - transfuse to Hct > 25\n - PIV x3\n - T+S\n - Sucralfate\n - IV protonix, octreotide drip\n - vitamin K 5mg was given x1: no improvement in INR\n - Liver recs: can start her on clears, but still N/V\n # Abd pain: Has history of chronic pancreatitis. Lipase mildly\n elevated. No need for imaging currently.\n - NPO\n - IVFs @ 200cc/hr\n - pain control\n # EtoH abuse\n - monitor per CIWA, ativan prn\n - MVT/thiamine/folate (banana bag daily\n - social work/ consult in AM\n # Anemia and thrombocytopenia Hct with appropriate bump from 2 units\n PRBCs. Plts down but likely consumption and now close to baseline\n - Trend Plt/Hct with transfusion plans as above\n # Alcoholic cirrhosis: Liver u/s consistent with cirrhosis but\n no evidence portal htn. AST/ALT >2 c/w EtoH\n - prophylactic cipro 400mg IV BID x 3 days ()\n - hold lasix and spironolactone in setting of bleed\n - hold lactulose while NPO\n #. Asthma\n - Continue home inhalers\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:55 PM\n 18 Gauge - 02:57 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2182-01-10 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 437644, "text": "Chief Complaint: Hematemesis\n HPI:\n 51 y.o. female with h/o ETOH abuse, pancreatitis (last admission\n ), cirrhosis, who presents from home after experiencing up to 10\n episodes of hematemesis. She denies having experienced this before.\n She has a h/o cirrhosis, but status of varices is unknown. Last RUQ\n ultrasound in showed patent antegrade flow through the portal\n vein. She reports using heroin 1 day prior to admission. Also reports\n being at ST \n In the ED, initial VS = 97.4, 102, 122/64, 20 , 100% ra. She looked\n very tremulous and smelled of ETOH, and there was initial concern for\n ETOH , valium 20mg IV x1 given. Labs revealed Hct of 20,\n PLTs of 100K, INR 1.5, ETOH 351. Her tox screen was positive for benzos\n and Opiates. NG lavage attempted without success, and with mild\n epistaxis. She was given 1liters NS, with 2nd liter and banana bag\n hanging. 3 PIVs established. Hepatology consulted, and recommended\n octreotide gtt, IV protonix and IV cipro which was done. Rectal exam\n showed no stool in vault and guiac negative. She was type and crossed,\n and admitted to MICU for monitoring. VS upon transfer: HR 97, 97/50,\n 16, 100%2L.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Penicillins\n Unspecified \n Last dose of Antibiotics:\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Other medications:\n HOME MEDS:\n Multivitamins PO Daily\n Folic Acid 1 mg PO Daily\n Thiamine 100mg PO Daily\n Lactulose 30 ML PO TID, titrate to 3 BMs daily\n Furosemide 80 mg PO Daily\n Spironolactone 50 mg PO DAILY\n Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\n Capsule, Delayed Release(E.C.) PO once a day.\n Advair 250-50 mcg/Dose \n Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule PO QID\n Albuterol Inhalation Q6H PRN\n Ambien 5mg\n Morphine SR - only 4 days were dispensed\n Past medical history:\n Family history:\n Social History:\n Alcoholic Cirrhosis\n Chronic pancreatitis\n ETOH abuse, with DT's in the past\n Asthma\n Uterine and cervical CA s/p hysterectomy\n Mother died at 72 from a GIB. Father .\n Occupation: Diabled. Used to be RN\n Drugs: heroin last night. Tox screen with benzos, opiates\n Tobacco: ppd\n Alcohol: Up to 1 gallon vodka a day\n Other:\n Review of systems:\n Flowsheet Data as of 05:50 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 97 (97 - 101) bpm\n BP: 90/44(55) {90/44(55) - 122/67(78)} mmHg\n RR: 19 (17 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 813 mL\n PO:\n TF:\n IVF:\n 813 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 813 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n General Appearance: Well nourished, No acute distress, smelled of ETOH\n Eyes / Conjunctiva: PERRL, anicteric sclerae\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Wheezes : expiratory)\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 104\n 108\n 0.7\n 9\n 28\n 105\n 3.6\n 144\n 30\n 6.8\n [image002.jpg]\n \n 2:33 A1/22/ 04:36 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 25.8\n Other labs: PT / PTT / INR:16.8/38.7/1.5, ALT / AST:22/67, Alk Phos / T\n Bili:102/1.8, Amylase / Lipase:/79, Differential-Neuts:49, Band:0,\n Lymph:39, Mono:7, Eos:5, Albumin:3.7\n Fluid analysis / Other labs: ETOH 351\n Urine tox: + benzos, + opiates\n Serum tox: negative\n Assessment and Plan\n This 51F with alcoholic cirrhosis presents with hematemesis.\n # Hematemesis: Presentation with UGIB, possibilities include variceal\n bleed given cirrhosis, PUD, gastritis, (unreliable hx\n from pt). Borderline BP 90/60, so will bolus NS\n - one liter NS now\n - follow Hct q6\n - transfuse to Hct > 25\n - PIV x3\n - T+S\n - IV protonix, octreotide drip\n - vitamin K 5mg\n - check EKG\n - Liver recommendations appreciated, EGD today\n # Abd pain: Has history of chronic pancreatitis. Lipase mildly\n elevated. No need for imaging currently.\n - NPO\n - IVFs @ 200cc/hr\n - pain control\n # EtoH abuse\n - monitor per CIWA, ativan prn\n - MVT/thiamine/folate (banana bag daily\n - social work/ consult in AM\n # Anemia and thrombocytopenia\n Hct above baseline of 25 at recent discharge, but did have recent\n transfusion of blood and platelets at . Baseline\n deficit likely due to chronic liver disease\n - Trend Plt/Hct with transfusion plans as above\n # Alcoholic cirrhosis: Liver u/s consistent with cirrhosis but\n no evidence portal htn. AST/ALT >2 c/w EtoH\n - prophylactic cipro 400mg IV BID\n - hold lasix and spironolactone in setting of bleed\n - hold lactulose while NPO\n - last liver u/s without evidence ascites and patent portal flow\n #. Asthma\n - Continue home inhalers\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 02:55 PM\n 18 Gauge - 02:57 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: with patient and HCP sister . ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2182-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 437625, "text": "51 yo F with PMHx of etoh/cirrhosis and chronic pancreatitis who is\n actively abuse alcohol, tobacco, and opiates. Presented to ED this AM\n with intoxication and hematemesis. Reports being at \n earlier this week where she was transfused. She does not endorse\n active bleeding around that time. This AM, felt nauseated, went the\n bathroom and vomitted large amount of BRB. EMS called and reported\n several more episodes of hematemesis in the interim.\n In the ED, received 1L NS and a banana bag. IV Cipro, IV Protonix, GI\n consulted. Started on octreotide gtt.\n Events: On arrival to MICU CIWA 7- pt very talkative/slightly slurred\n speech consistently asking for pain medications. Hemodynamically\n stable- Hr 90\ns, BP stable 100-120\ns/, no N/V.\n .H/O pancreatitis, chronic\n Assessment:\n soft rounded distended abd, c/o10/10 pain @ rest > pain w/\n palpation- mild\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2182-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 437623, "text": "51 yo F with PMHx of etoh/cirrhosis and chronic pancreatitis who is\n actively abuse alcohol, tobacco, and opiates. Presented to ED this AM\n with intoxication and hematemesis. Reports being at \n earlier this week where she was transfused. She does not endorse\n active bleeding around that time. This AM, felt nauseated, went the\n bathroom and vomitted large amount of BRB. EMS called and reported\n several more episodes of hematemesis in the interim.\n In the ED, received 1L NS and a banana bag. IV Cipro, IV Protonix, GI\n consulted. Started on octreotide gtt.\n Events: On arrival to MICU CIWA 7- pt very talkative/slightly slurred\n speech consistently asking for pain medications. Hemodynamically\n stable- Hr 90\ns, BP stable 100-120\ns/, no N/V.\n" }, { "category": "Radiology", "chartdate": "2182-01-11 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1058508, "text": " 2:38 PM\n US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: CIRRHOSIS, PLEASE PERFORM DOPPLERS TO EVAL FOR PV THROMBOSIS, EVAL LIVER\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with ESLD EtOH p/w variceal bleeding\n REASON FOR THIS EXAMINATION:\n please perform dopplers to eval for PV thrombosis, eval liver fro echotexture\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy 6:35 PM\n Normal flow is seen in the portal vein, hepatic veins, and splenic vein.\n Livers appears cirrhotic, however full evaluation limited due to the patient\n refusal to continue the study. There is no ascites. The spleen is enlarged.\n A small right pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old female with alcoholic cirrhosis, presenting with\n variceal bleeding. Evaluate for portal vein thrombus.\n\n COMPARISON: Abdominal ultrasound dated .\n\n FINDINGS: The left, right, and main portal veins are well visualized and\n demonstrate normal antegrade flow. Normal flow was also seen in the left,\n middle, and right hepatic veins. Limited views of the liver parenchyma\n demonstrate a nodular, cirrhotic contour, consistent with provided history. No\n focal lesions are identified. Spleen measured 14 cm. There is no ascites. A\n small right pleural effusion is noted.\n\n Further evaluation was not possible given patient refusal to complete this\n study.\n\n IMPRESSION:\n 1. Nodular, cirrhotic liver without focal lesion, however, full evaluation is\n limited by patient's refusal to continue exam.\n\n 2. Normal flow is seen in the portal vein, hepatic veins, and splenic vein.\n\n 3. Splenomegaly. No ascites.\n\n 4. Right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-01-11 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1058509, "text": ", MED MICU-7 2:38 PM\n US ABD LIMIT, SINGLE ORGAN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: CIRRHOSIS, PLEASE PERFORM DOPPLERS TO EVAL FOR PV THROMBOSIS, EVAL LIVER\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with ESLD EtOH p/w variceal bleeding\n REASON FOR THIS EXAMINATION:\n please perform dopplers to eval for PV thrombosis, eval liver fro echotexture\n ______________________________________________________________________________\n PFI REPORT\n Normal flow is seen in the portal vein, hepatic veins, and splenic vein.\n Livers appears cirrhotic, however full evaluation limited due to the patient\n refusal to continue the study. There is no ascites. The spleen is enlarged.\n A small right pleural effusion.\n\n" }, { "category": "ECG", "chartdate": "2182-01-14 00:00:00.000", "description": "Report", "row_id": 148931, "text": "Sinus rhythm. Loss of R waves in the anterior leads which is non-diagnostic.\nCompared to the previous tracing of sinus tachycardia has resolved.\nOtherwise, no other significant diagnostic change.\n\n" }, { "category": "Radiology", "chartdate": "2182-01-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058264, "text": " 12:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? cp process\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with UGIB\n REASON FOR THIS EXAMINATION:\n ? cp process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:06 PM\n No pneumonia or congestive heart failure.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 51-year-old female with upper gastrointestinal\n bleeding. Please evaluate for acute cardiopulmonary process.\n\n EXAMINATION: Single upright portable chest radiograph.\n\n COMPARISONS: Comparison to chest radiographs from .\n\n FINDINGS: Low lung volumes accentuate a normal cardiomediastinal silhouette\n and pulmonary vascular crowding. The lungs are clear with no signs of\n pneumonia or congestive heart failure. The skeletal structures are grossly\n within normal limits.\n\n IMPRESSION: No pneumonia or congestive heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-01-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058265, "text": ", R. MED TSICU 12:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? cp process\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with UGIB\n REASON FOR THIS EXAMINATION:\n ? cp process\n ______________________________________________________________________________\n PFI REPORT\n No pneumonia or congestive heart failure.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2190-02-06 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1179867, "text": " 10:07 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: EVALUATE FOR INCARCERATED HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with ? incarcerated ventral hernia, please do not give IV or\n PO contrast, page (surgery resident) for questions on CT\n REASON FOR THIS EXAMINATION:\n eval hernia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdomen and pelvis CT .\n\n COMPARISON: .\n\n INDICATION: Evaluate for incarcerated hernia.\n\n TECHNIQUE: Multiple contiguous axial images were obtained from the lung bases\n to the greater trochanters. Coronal and sagittal reformatted images were\n obtained. No IV or oral contrast was administered.\n\n FINDINGS: A small approximately 5-mm pulmonary nodule is seen in the right\n lower lobe. This may have been seen on the prior study. No other definite\n pulmonary nodules. No pleural effusions. No pericardial fluid. Extensive\n coronary artery calcifications and atherosclerotic calcifications.\n\n Lack of IV contrast limits evaluation of the solid organs. No intrahepatic or\n extrahepatic bile duct dilation. The gallbladder is normal. Normal adrenal\n glands. No pelvocaliectasis. There is an exophytic rounded cyst within the\n left kidney measuring approximately 1.9 x 2.2 cm. This demonstrates fluid\n density and most likely represents a simple cyst. The bladder is distended\n with fluid and demonstrates normal wall thickness. Patient is status post\n hysterectomy.\n\n The large and small bowel are of normal caliber and without wall thickening.\n No dilated loops of bowel. There is a large ventral periumbilical hernia with\n a wide neck measuring approximately 5.3 cm. The periumbilical hernia contains\n mesentery and large bowel. The bowel within the hernia is non-obstructed. No\n stranding within the hernia. There has been increase in fluid within the\n hernia sac. Multiple diverticula are noted.\n\n No free fluid within the abdomen or pelvis. No gross lymphadenopathy. No\n free air.\n\n No aggressive osseous lesions. Degenerative changes of the SI joints and\n lumbar spine. There is a compression fracture of L3 vertebral body, which is\n not significantly changed and demonstrates greater than 50% vertebral body\n height loss.\n\n IMPRESSION:\n 1. Large periumbilical ventral hernia containing large bowel and fluid. No\n evidence for obstruction or incarceration.\n (Over)\n\n 10:07 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: EVALUATE FOR INCARCERATED HERNIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Diverticulosis.\n 3. Probable left renal simple cyst.\n 4. Small 5-mm right lower lobe pulmonary nodule. This may have been seen on\n the prior study. Attention on follow-up.\n 5. Unchanged L3 compression fracture.\n\n The findings of the bowel were discussed with Dr. on at 10:35\n a.m.\n\n" }, { "category": "ECG", "chartdate": "2190-02-06 00:00:00.000", "description": "Report", "row_id": 263950, "text": "Baseline artifact. Sinus rhythm. T wave flattening in lead aVF.\nNo previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2180-04-15 00:00:00.000", "description": "INTERUP IVC", "row_id": 866306, "text": " 6:24 PM\n IVC GRAM/FILTER Clip # \n Reason: See below\n Admitting Diagnosis: S/P 25 FT FALL\n Contrast: OMNIPAQUE Amt: 30\n ********************************* CPT Codes ********************************\n * INTERUP IVC INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n * C1880 VENA CAVA FILTER NON-IONIC LESS THAN 100CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with long bone fx of leg and prolong immobilziation\n REASON FOR THIS EXAMINATION:\n See below\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post trauma with prolonged expected bedridden course and\n inability to anticoagulate.\n\n RADIOLOGISTS: Dr. and Dr. . Dr. , staff radiologist, was\n present for the entire procedure.\n\n Details of the procedure and possible complications were explained to the\n patient and informed consent was obtained.\n\n TECHNIQUE: Using sterile technique, local anesthesia and conscious sedation\n the left common femoral vein was punctured and tract was dilated with a 7-\n French dilator. A 7-French sheath was advanced over the wire with its tip\n positioned at the confluence of the iliac veins. Cavogram was then performed.\n Both renal veins were identified at the level of superior aspect of L1\n vertebral body. Under fluoroscopic guidance with the help of a guide wire the\n sheath was advanced forward and its tip positioned at the level of mid L1\n vertebral body. A retrievable IVC filter was then advanced through the sheath\n and deployed into the infrarenal IVC under fluoroscopic guidance. The sheath\n was then removed and hemostasis was achieved.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n CONTRAST MATERIAL: 35 cc of nonionic contrast material were used.\n\n IMPRESSION: Uncomplicated retrievable filter placement into the infrarenal\n IVC. The filter can be retrieved from the jugular approach at any time when\n the patient is no longer at risk for PE or can be safely anticoagulated.\n\n\n\n\n (Over)\n\n 6:24 PM\n IVC GRAM/FILTER Clip # \n Reason: See below\n Admitting Diagnosis: S/P 25 FT FALL\n Contrast: OMNIPAQUE Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 866146, "text": " 11:54 AM\n PELVIS (AP ONLY); -76 BY SAME PHYSICIAN # \n Reason: eval for alignment\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with hip fx s/p traction\n REASON FOR THIS EXAMINATION:\n eval for alignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hip fracture with traction.\n\n Single AP bedside radiograph of the right hemipelvis and proximal femur.\n Since initial examination earlier same day, there has been diminution in the\n varus deformity of the markedly comminuted and displaced intertrochanteric\n fracture of the proximal femur.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-15 00:00:00.000", "description": "R FEMUR (AP & LAT) RIGHT", "row_id": 866302, "text": " 6:06 PM\n FEMUR (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: RT FEMUR RODING\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Operative films for femur rodding.\n\n FINDINGS:\n\n Initial images demonstrate the intertrochanteric fracture and subsequent\n images show a femoral rod and compression screw, the latter extending through\n to the femoral neck and head. Additional views extend down the shaft of the\n femur and demonstrate securing screws coursing perpendicular to the\n intramedullary rod.\n\n" }, { "category": "Radiology", "chartdate": "2180-04-18 00:00:00.000", "description": "T-SPINE", "row_id": 866634, "text": " 4:40 PM\n T-SPINE Clip # \n Reason: kyphosis , displacement\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with T12 Burst fracture\n REASON FOR THIS EXAMINATION:\n kyphosis , displacement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: T12 burst fracture.\n\n THORACOLUMBAR SPINE AP AND LATERAL ON : Comparion MR . L1 burst\n fracture identified on MR is not seen on these images. Given the lateral\n images are coned at the mid thoracolumbar spine, it is very difficult to count\n vertebral body level. An IVC filter is incompletely imaged to the right of L1.\n\n IMPRESSION: Lateral images are cone at thoracolumbar spine and exact level\n numbering is difficult. L1 fracture is not seen on these images. Repeat\n lateral image of the lumbar spine is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2180-04-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 866362, "text": " 11:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate/effusion\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with chest tube after trauma\n\n REASON FOR THIS EXAMINATION:\n eval for infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check chest tube.\n\n COMPARISON: .\n\n FINDINGS: The right lateral aspect of the right chest wall is obscured from\n view. The visualized portion of the chest tube is seen extending medially\n with its tip near the hilum and the side port within the chest cavity. There\n is no pneumothorax visualized. Shallow inspiration limits the assessment for\n pneumomediastinum and there is left basilar atelectasis. Pulmonary vascular\n markings are within normal limits.\n\n At the edge of the film, an IVC filter is incidentally seen and some central\n abdominal skin staples noted.\n\n IMPRESSION:\n Shallow inspiration and bibasilar atelectasis; no pneumothorax. Right chest\n partially obscured from view.\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "R ELBOW (AP, LAT & OBLIQUE) RIGHT", "row_id": 866131, "text": " 10:21 AM\n ELBOW (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: Eval for fx, dislocation, foreign body\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with R elbow laceration, s/p fall\n REASON FOR THIS EXAMINATION:\n Eval for fx, dislocation, foreign body\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n AP and lateral views of the right elbow are not technically optimal apparently\n due to difficulties in positioning. No fracture identified and I doubt the\n presence of a joint effusion. Equivocal soft tissue abnormality medially.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-18 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 866652, "text": " 9:32 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o new infiltrate/effusion\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with L1 fracture and fever spike to 101.5\n\n REASON FOR THIS EXAMINATION:\n r/o new infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old man with fever.\n\n TECHNIQUE: Frontal view of the chest.\n\n COMPARISON: Chest x-ray dated .\n\n FINDINGS: Cardiac and mediastinal contours are unchanged compared to the\n prior study. Previously noted small right pneumothorax has filled with fluid.\n Again note is made of left lower lobe retrocardiac opacity.\n\n IMPRESSION: Previously noted right pneumothorax has filled with pleural\n effusion. Persistent left lower lobe retrocardiac opacity, which probably\n representing pneumonia in this patient with fever.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-18 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 866653, "text": " 9:32 PM\n L-SPINE (AP & LAT) Clip # \n Reason: interval films\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with L1 fracture\n REASON FOR THIS EXAMINATION:\n interval films\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 37-year-old man with L1 burst fracture for followup.\n\n LUMBAR SPINE, AP AND LATERAL: Comparison is made to the recent MR, and to the\n radiographs of . An inferior vena cava filter is identified on the AP\n view, likely in similar position. There is diffuse mild dilatation of several\n loops of small bowel, and of the proximal colon, consistent with ileus. There\n are surgical staples overlying the midline, probably from a recent laparotomy.\n\n Again seen is a compressive fracture of L1 with loss of about 25-50% of the\n vertebral body height, similar to the prior study. There is again seen mild\n kyphotic angulation at the fracture site. However, there is no listhesis. No\n fracture is identified elsewhere. There is an unfused apophysis along the\n anterosuperior margin of L4.\n\n IMPRESSION: Similar appearance of L1 compression fracture. Mildly dilated\n small and large bowel loops, representing post-operative ileus.\n\n" }, { "category": "Radiology", "chartdate": "2180-04-22 00:00:00.000", "description": "LUMBAR SP,SINGLE FILM", "row_id": 867130, "text": " 2:55 PM\n LUMBAR SP,SINGLE FILM Clip # \n Reason: PT IN OR LAMINIECTOMY\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n FINAL REPORT\n Laminectomy\n\n Three interoperative portable films taken during sequence of the laminectomy\n shows hardware placed during the procedure at exact positioning clarity is\n uncertain due to the portable technique.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 866108, "text": " 9:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for acute head trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n Eval for acute head trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SADk FRI 10:35 AM\n no hemorrhage or fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Head trauma.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage, shift of normally midline\n structures, mass effect, or hydrocephalus. The -white matter\n differentiation is intact. There is no major vascular territorial infarct.\n The osseous structures are normal without acute fracture. There is minimal\n mucosal thickening within the ethmoid air cells. The sinuses are otherwise\n clear.\n\n IMPRESSION: No intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-26 00:00:00.000", "description": "T-SPINE", "row_id": 867592, "text": " 11:40 AM\n T-SPINE Clip # \n Reason: hardware position\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with T12 fracture s/p posterior spinal fusion. Please show\n entire hardware T8-L2. do XR supine and side lying.\n REASON FOR THIS EXAMINATION:\n hardware position\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: T12 fracture. Status post posterior spinal fusion.\n\n THORACOLUMBAR SPINE AP & LATERAL: Patient is status post posterior fusion from\n T8/L2 with pedicle screws at L1, L3 and L4 and long posterior rods with\n laminar hooks, transfixing a T12 compression fracture. Since , skin\n staples have been removed. IVC filter is no longer perceptible. There is\n loss of normal lumbar lordosis. Gasseous distention of the small and large\n bowel is incompletely visualized.\n\n IMPRESSION: Status post T8-L2 posterior fusion for T12 compression fracture.\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 866211, "text": " 8:22 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: CT placement\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with chest tube after trauma\n REASON FOR THIS EXAMINATION:\n CT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old man with right chest tube.\n\n Portable AP view of the chest dated , shows the left hemithorax is\n excluded from the film. An NG tube is coiled in the stomach. A right chest\n tube terminates in the medial right mid lung. There is poor inspiratory\n effort, and therefore, the lung volumes are low. No focal areas of\n consolidation within the lung fields are seen. There are no pleural\n effusions. There is no discernable pneumothorax.\n\n IMPRESSION: Lines and tubes as described above. No identifiable\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "LUMBAR SP,SINGLE FILM", "row_id": 866140, "text": " 11:13 AM\n LUMBAR SP,SINGLE FILM Clip # \n Reason: Eval fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with L1 fracture\n REASON FOR THIS EXAMINATION:\n Eval fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma. Assess L1 fracture.\n\n This exam consists of two lateral radiographs of the L/S spine. There is 30%\n loss of anterior height of L1 body involving the superior endplate. The\n remainder of the vertebral bodies are essentially normal with disk narrowing\n at L4-5. Residual contrast medium urinary tract. I have no AP frontal\n radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "MR L SPINE SCAN", "row_id": 866152, "text": " 12:31 PM\n MR L SPINE SCAN Clip # \n Reason: Please also get STIR images. Eval fx and cord\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with L1 (he has 6 lumbar vertebrae) fx on CT scan w/ cord\n compression. s/p 20 foot fall.\n REASON FOR THIS EXAMINATION:\n Please also get STIR images. Eval fx and cord\n ______________________________________________________________________________\n WET READ: SADk FRI 4:00 PM\n T12 fracture with retropulsed fragments and cord compression, with probable\n subdural collection, see t-spine report\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma, L1 vertebral body fracture seen on CT.\n\n TECHNIQUE: Multiplanar T1 and T2 imaging of the lumbar spine.\n\n FINDINGS: There is evidence of a burst fracture of the L1 vertebral body with\n retropulsion of the fracture fragments posteriorly. There appears to be cord\n compression at the conus medullaris at this level.\n\n There appears to be abnormal signal extending from the upper T12 through L2\n vertebral bodies, assuming six lumbar vertebrae, which appears to be separate\n from the epidural space and consistent with a subdural hematoma.\n\n At L4-L5, there is a central disk bulge, which indents the thecal sac, but no\n cauda equina compression.\n\n The remainder of the vertebral bodies appear normal in signal intensity.\n\n The posterior elements do not appear to be involved.\n\n IMPRESSION: L1 vertebral body burst fracture with retropulsion of the\n fracture fragments and compression of the conus medullaris. Subdural hematoma\n centering at this level. A wet read was put into the CCC ER dashboard at 4:30\n p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 866490, "text": " 1:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with chest tube after trauma s/p chest tube removal\n\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post chest tube removal, assess for pneumothorax.\n\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH: Comparison is made to one day earlier.\n\n FINDINGS: The right chest tube has been removed. There is a small right\n lateral and basilar pneumothorax. Linear atelectatic changes at the left lung\n base are unchanged. There is no new consolidation. Pulmonary vasculature is\n normal.\n\n IMPRESSION: Interval removal of right-sided chest tube, with small right\n lateral and basilar pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "MR THORACIC SPINE", "row_id": 866151, "text": " 12:30 PM\n MR THORACIC SPINE Clip # \n Reason: Please get STIR images. Please eval fx and cord.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with L1 (he has 6 lumbar vertebrae) fx on CT scan w/ cord\n compression. s/p 20 foot fall.\n REASON FOR THIS EXAMINATION:\n Please get STIR images. Please eval fx and cord.\n ______________________________________________________________________________\n WET READ: SADk FRI 3:59 PM\n T12 fracture with retropulsed fragments posteriorly, cord compression,\n extraaxial compression, likely subdural.\n WET READ VERSION #1 SADk FRI 3:52 PM\n T12 fracture with retropulsed fragments posteriorly. see lumbar spine\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: Trauma, L1 fracture.\n\n TECHNIQUE: Multiplanar T1 and T2 imaging through the thoracic spine.\n\n FINDINGS: In agreement with the lumbar spine MRI, there is a fracture of the\n L1 vertebral body with retropulsion of fracture fragments posteriorly and\n compression of the conus medullaris.\n\n There is a right disk protrusion at T9-10, but no cord compression at this\n level.\n\n The remainder of the vertebral bodies within the thoracic spine have normal\n signal intensity and alignment.\n\n IMPRESSION: As described in detail on the lumbar spine MRI, there is a L1\n vertebral body fracture with retropulsion of the fracture fragments and\n compression of the conus medullaris.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 866109, "text": " 9:09 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: Eval for acute trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n Eval for acute trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SADk FRI 11:04 AM\n right apical pneumothorax. no cspine fractures\n WET READ VERSION #1 SADk FRI 10:42 AM\n right apical pneumothorax. no cspine fractures seen, awaiting recons\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: Trauma.\n\n TECHNIQUE: Noncontrast axial images through the cervical spine with coronal\n and sagittal reformats.\n\n FINDINGS: There is no cervical spine fracture. There is normal anatomic\n alignment. There is no prevertebral soft tissue swelling. The vertebral body\n height and intervertebral disc spaces are maintained. Note is made of a small\n right apical pneumothorax.\n\n IMPRESSION: No cervical spine fracture. Right apical pneumothorax. These\n findings were provided to the ER CCC Dashboard at the time of the study.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 866111, "text": " 9:10 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT RECONSTRUCTION\n -59 DISTINCT PROCEDURAL SERVICE; CT 150CC NONIONIC CONTRAST\n Reason: Eval for acute trauma\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n Eval for acute trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MJGe FRI 10:54 AM\n 1. Compression burst fracture through body of 1st lumbar vertebral body, and\n lamina with 50% impingement into the spinal canal at this level from the\n fracture fragments. Spinal stabilization should be performed along with\n neurologic evaluation.\n\n 2. Small amount of intraperitoneal blood concerning for mesenteric vascular\n injury.\n\n 3. Right intertrochanteric hip fracture, and proximal right femur fracture.\n\n 4. Small right apical pneumothorax with no identifiable rib fracture.\n\n d/ , and dr. \n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: 37-year-old man status post fall from an extended height,\n evaluate for acute trauma.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis with trauma\n protocol using fast bolus 150 cc of nonionic Optiray contrast with coronal and\n sagittal reformations.\n\n CT CHEST WITH IV CONTRAST: The airways are patent to the segmental level.\n There is a tiny right basilar pneumothorax. The lungs are otherwise clear\n without evidence of contusion, consolidation, or effusion. Bibasilar\n atelectasis. Heart and pericardium are unremarkable. No fractures are\n detected within the ribs, or the cervical and upper thoracic spine. There\n appears to be normal and preserved alignment of the cervical and thoracic\n vertebral bodies. There is no evidence of impingement upon the cord at this\n level. There are no pathologically enlarged lymph nodes in the axilla,\n mediastinal, and hilar distribution. There is no evidence of aortic arch or\n other arterial injury within the thorax. The main pulmonary artery and its\n major segmental branches are unremarkable.\n\n CT ABDOMEN WITH IV CONTRAST: There is a small amount of hemoperitoneum, with\n high-density fluid surrounding the liver anteriorly and laterally, and\n tracking inferiorly in the right subhepatic space, and into the right\n (Over)\n\n 9:10 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT RECONSTRUCTION\n -59 DISTINCT PROCEDURAL SERVICE; CT 150CC NONIONIC CONTRAST\n Reason: Eval for acute trauma\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n pericolic gutter. There is no evidence of laceration, contusion, or other\n injury to the liver, gallbladder, spleen, pancreas, kidneys, and adrenal\n glands. There is no extravasation of arterial contrast or contrast within the\n collecting system to suggest vascular or collecting system injury. Stomach\n and proximal small bowel are unremarkable. There is no free air in the\n abdomen. There is no free air in the upper abdomen.\n\n CT PELVIS WITH IV CONTRAST: Within the small bowel mesentery, best seen on\n series 2, image 58, there is a pocket of high density fluid, concerning for\n mesenteric vascular injury. There is stranding at this level surrounding the\n cecum. The remaining intrapelvic small bowel is unremarkable. Foley catheter\n is in place in a distended bladder. There is no evidence to suggest bladder\n rupture. There is no free fluid in the pelvis. The intrapelvic colon is\n normal. There are no pathologically enlarged lymph nodes.\n\n BONE WINDOWS: There is a comminuted right intratrochanteric fracture. There\n is a tiny linear lucency at the lateral aspect of the right iliac crest, which\n may represent a small nondisplaced fracture versus a nutrient foramen. In\n favor of fracture, is asymmetry and enlargement of the nearby iliacus muscle,\n suggesting a small intramuscular hematoma. There is a comminuted, mildly\n depressed burst fracture through the vertebral body of L1. There appears to\n be six lumbar vertebrae. The fracture line extends into the right- sided\n posterior elements of L1 and involves the facet joint. There is retropulsion\n of several fragments of the vertebral body posteriorly into the vertebral\n canal, with 25-50% encroachment upon the canal at this point, and apparent\n impingement upon the cord.\n\n IMPRESSION:\n 1) Hemoperitoneum, with a pocket of high attenuation fluid consistent with\n blood within the small bowel mesentery, concerning for mesenteric vascular\n injury. Small amount of blood surrounding the liver, without evidence of\n hepatic injury.\n 2) No evidence of other intra-abdominal/pelvic major organ injury or aortic\n injury. No evidence of extravasation of arterial contrast or collecting system\n contrast.\n 3) Small right-sided pneumothorax.\n 4) Burst fracture of the L1 vertebral body (there are six lumbar vertebrae),\n with extension into the right-sided posterior elements and involving the facet\n joint. Approximately 50% retropulsion of several vertebral body fragments into\n the spinal canal, impinging and compressing the spinal cord at this level.\n Correlate with clinical symptoms.\n 5) Comminuted, displaced right intratrochanteric fracture.\n 6) Probable subtle nondisplaced 4th right, posterior rib fracture.\n 7) Subtle linear lucency at the lateral aspect of the right iliac crest, which\n (Over)\n\n 9:10 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT RECONSTRUCTION\n -59 DISTINCT PROCEDURAL SERVICE; CT 150CC NONIONIC CONTRAST\n Reason: Eval for acute trauma\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n may represent a small nondisplaced fracture versus a nutrient foramen. Slight\n assymetric enlargement of the iliacus muscle at this level, suggesting a\n possible small intramuscular hematoma. See dedicated CT pelvis bone algorithm\n CT under separate clip number.\n 8) Cortical fragment anterior to the superior endplate of L5 which appears\n more likely to represent a degenerative osteophyte than an acute fracture.\n Again see dedicated CT pelvis under separate clip number.\n 9) Decompressed bladder with Foley, without evidence of bladder injury, though\n a CT cystogram would be much more sensative to assess for this if there is\n clinical suspicion.\n\n Findings communicated by Dr. to the surgical team immediately after\n the study.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 867340, "text": " 2:33 PM\n CHEST (PA & LAT) Clip # \n Reason: r/out PNA\n Admitting Diagnosis: S/P 25 FT FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with productive cough and fever, trauma patient immobilized\n\n REASON FOR THIS EXAMINATION:\n r/out PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of productive cough and fever. Rule out pneumonia.\n\n COMPARISON: Study from 5/17/5.\n\n PORTABLE AP CHEST RADIOGRAPH: There is a left retrocardiac opacity, which\n appears more prominent in comparison to prior study, and may represent a\n worsening infiltrate in this area. The right lung fields are clear. No\n pleural effusion is seen. No pneumothorax is seen. Soft tissue and osseous\n structures are stable in appearance. There has been interval placement of\n rods, which overlie the lower thoracic spine.\n\n IMPRESSION: Worsening left retrocardiac opacity, which probably represents\n infectious consolidation, though this could be, less likely, atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "P TRAUMA #2 (AP CXR & PELVIS PORT) PORT", "row_id": 866112, "text": " 9:11 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) PORT Clip # \n Reason: Eval for acute injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n Eval for acute injury\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Major trauma. Trauma series.\n\n AP film of the pelvis obtained on the trauma board. There is a markedly\n comminuted displaced intertrochanteric fracture of the proximal right femur\n with varus deformity. The left hip is poorly visualized with probable\n degenerative changes and joint space narrowing. No bone destruction.\n\n AP bedside chest radiograph obtained on trauma board. Allowing for supine\n technique, the heart and mediastinum are normal with no vascular congestion,\n consolidations, or effusions. The left lateral thorax is not imaged. No\n fracture identified.\n\n IMPRESSION: Fracture right femur. Degenerative changes left hip. Normal\n chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-25 00:00:00.000", "description": "INTRA VAS FB RETRIEVAL", "row_id": 867412, "text": " 7:07 AM\n IVC GRAM/FILTER Clip # \n Reason: removal of IVC filter\n Admitting Diagnosis: S/P 25 FT FALL\n Contrast: OPTIRAY Amt: 30\n ********************************* CPT Codes ********************************\n * INTRA VAS FB RETRIEVAL 78 RELATED PROCEDURE DURING POSTOPER *\n * INTRO CATH SVC/IVC -51 MULTI-PROCEDURE SAME DAY *\n * TRANSCATHETER RETRIEVAL INTRAV C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with long bone fx of leg and prolong immobilziation, now able\n to be on Lovenox, please remove filter--placed by IR\n REASON FOR THIS EXAMINATION:\n removal of IVC filter\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n HISTORY: This is a 37-year-old man with multiple fractures following fall.\n\n RADIOLOGIST: The procedure was performed by Dr. and Dr.\n . Dr. , the attending radiologist, was present and\n supervising throughout the procedure.\n\n CONSENT: After receiving explanation of the benefits and risks of the\n procedure, written informed consent was obtained from the patient.\n\n TECHNIQUE: The patient was placed supine on the angiography table. The right\n side of the neck was prepared in a sterile fashion. After local anesthesia\n with 8 cc of lidocaine 1%, access was gained to the right internal jugular\n vein with a 21-gauge needle under ultrasonographic guidance. A 0.018\n guidewire was advanced through the needle through the superior vena cava. The\n needle was removed over the wire, and a micropuncture sheath was inserted into\n the vein, and a 0.035 guidewire was advanced through the sheath under\n fluoroscopic guidance into the inferior vena cava. A 5 French sheath was then\n advanced over the wire followed by a 5 French straight multi-perforated\n catheter. An inferior cavogram was obtained and showed no evidence of clot\n trapped in the recovery IVC filter. The sheath was then removed and exchanged\n for a 10 French filter-removal long sheath. Under fluoroscopic guidance, the\n removal device was advanced through the sheath over the filter. The filter\n was successfully retrieved under fluoroscopic guidance. The filter, the\n sheath, and the wire were removed, and pressure was held until hemostasis was\n achieved. A dressing was applied.\n\n ANESTHESIA: Besides local anesthesia, the patient received IV moderate\n sedation with fractionated doses of Versed and fentanyl.\n\n (Over)\n\n 7:07 AM\n IVC GRAM/FILTER Clip # \n Reason: removal of IVC filter\n Admitting Diagnosis: S/P 25 FT FALL\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Successful retrieval of an IVC recovery filter.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 866120, "text": " 9:38 AM\n CT PELVIS W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CT RECONSTRUCTION; -59 DISTINCT PROCEDURAL SERVICE\n Reason: Eval for pelvic fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with femur fracture s/p 5-20 feet\n REASON FOR THIS EXAMINATION:\n Eval for pelvic fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Femur fracture. Evaluate for pelvic fracture.\n\n TECHNIQUE: Noncontrast MDCT images of the pelvis were acquired. Coronal and\n sagittal reconstructions were made.\n\n COMPARISON: Pelvic CT scan from earlier the same day.\n\n CT OF THE PELVIS WITHOUT CONTRAST: As seen on the prior study, there is a\n comminuted intratrochanteric fracture of the right femur. The lesser\n trochanter is a separate fracture fragment. There is impaction of the distal\n fracture fragments, with abduction of the head and neck fragments. The lucency\n described on trauma torso CT scan in right ilium is normal nutrient foramen.\n\n There are severe degenerative changes within the left hip with complete loss\n of articular cartilage and extensive osteophyte formation. The configuration\n of the femoral head does not suggest prior etiology such as -calve-Perthes\n disease or from prior slipped capital femoral epiphysis. Mild degenerative\n changes are seen within the distal spine.\n\n Evaluation of the soft tissues shows asymmetrical muscle mass with prominent\n atrophy of all the left pelvic muscles including the gluteal muscles,\n iliopsoas muscles, hip flexor muscles, and adductor muscles. No contrast is\n seen to leak from the bladder. The amount of fluid in the pelvis is\n unchanged. Vascular calcifications are present.\n\n IMPRESSION: Comminuted intratrochanteric fracture of the right proximal femur.\n The lesser trochanter is a separate fragment. Severe degenerative changes\n opposite left hip, without evidence for underlying etiology (LCPerthes or\n SCFE). Associated muscular atrophy of all pelvic and proximal leg muscles on\n the left. Lucency previously described in right ilium represents a normal\n nutrient foramen. No other pelvic fracture is seen. Vascular calcification\n are abnormal in this age group.\n\n" }, { "category": "Radiology", "chartdate": "2180-04-14 00:00:00.000", "description": "R FEMUR (AP & LAT) RIGHT", "row_id": 866122, "text": " 10:18 AM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: Eval fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with femur fracture\n REASON FOR THIS EXAMINATION:\n Eval fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma. Known fracture right femur.\n\n Four views of the right femur again show a comminuted displaced right\n intertrochanteric fracture with varus deformity. The remainder of this femur\n is intact. Tricompartmental degenerative changes in the right knee with\n medial joint space narrowing. (suboptimally assessed with knee radiographs\n not obtained, but no fracture in this area).\n\n\n" }, { "category": "ECG", "chartdate": "2180-04-21 00:00:00.000", "description": "Report", "row_id": 193181, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-17 00:00:00.000", "description": "Report", "row_id": 1416717, "text": "T-SICU NPBN 1900-0700\nSee carevue for specifics.\nROS:\nNeuro: Sleeping on/off; easily arousable. A+Ox3, conversing appropriately; confusion cleared since yesterday. MAE's, follows commands, restraints off and cooperative with care. Normal strength of BUE's, wiggles toes on RLE, able to weakly lift LLE. Pedal pulses palpable, +sensation throughout. c/o lower back/abd/R leg/hip pain at 7-8 on scale 0-10, subsides to with 2mg dilaudid q2-3hrs per pt report. Logroll precautions maintained; measured for brace over weekend (T12 burst fx), brace to be placed today.\n\nCV: HR 90-100's ST, occ. APC's, BP 100-120's/60-80's. Skin warm, dry. Pedal pulses palpable. PB's, IVC filter placed . PIV's x3 wnl.\nHeme: hct 26.6 (26.1) from 30.9 am labs yesterday, Dr. aware.\n\nResp: LS coarse throughout; weak cough with encouragement, expectorating sm. amts. thick white sputum, spec sent for culture. RR 20's, O2sats 95-100% on 100% face tent; stats 93-94% on RA. Instructed on IS; reaching 500ml.\n\nGI: abd softly distended, BS distant, hypoactive, no BM/flatus. Denies n/v. Tol. sips clear liquids. Pepcid for GI prophylaxis.\n\nGU: foley patent draining clear yellow urine in adequate amts. Lytes repleted as ordered.\n\nEndo: BS covered per SS.\n\nID: tmax 102 ax; pan cultured. No current abx coverage.\n\nSkin: back ; sm. bruise noted to gluteal fold. R elbow lac with sutures , no drainage, OTA. R hip/knee dsgs , no drainage, to be changed by ortho prn. Abd dsg ,C/D/I. Angio site wnl, no hematoma noted.\n\nPsych/social: few friends in to visit last early eve; no contact \n\nA: improved MS, cooperative with care; temp 102, pan cultured; hemodynamically stable\n\nP: Monitor VS, I/O, labs/cultures. Enc. aggressive pulmonary hygiene, C+DB, IS. Assess pain, med. prn. Await brace placment today. Continue ongoing comfort/support to pt.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-17 00:00:00.000", "description": "Report", "row_id": 1416718, "text": "T/Sicu NSg Note\n0700>>\n\nEVENTS: TLSO brace arrived this am>>placed on pt>>now sitting up in bed and OOB to chair!\n Ongoing pain mngmnt issues>>PCA restarted\n Secretions clearance improved with position changes>>weaned fio2.\n Temp spike to 101.4\n Clear diet started.\n\n\nNeuro- A&O x3, moves UE's with normal strength; lower extremities move on bed..limited by pain & stiffness. Denies sensation changes in LE's.\nOngoing c/o pain in abd/right hip/back, rated ..sharp.\nPrecedex d/c'd @ 0930. Pt requesting dilaudid exactly q2/hr. Mngmnt changed to PCA. Pt states that the effects are now more 'constant' but he cont to rate his pain ~ . He states that \"everything is fine but his abdomen\". He denies gas pain and can not further explain or describe the character/quality of this ongoing discomfort.\nTLSO brace in place and pt now sitting up and getting OOB with PT for the first time.\nAtivan dosing decreased to 1mg ivp q8/hr.\n\nCVS- VSS with tachyardia increasing with temp increase.\n IVF cont @ 125cc/hr\n\nRenal- adequate hourly u/o\n electrolytes repleted\n\nRESP- ineffective secretion clearance in supine position..now improved in upright position: pt coughing effectively and clearing thick white sputum. RR teens to 20's w/o c/o distress. Breath sounds are coarse throughout. Fio2 has been weaned from 100% to 50-60%\nwith sats maintianed mid to high 90's.\n\nID- temp spike to 101.4 Cultures from pending. No antibiotics currently.\n\nGI- soft/distended abd; hypoactive bowel sounds. Pepcid cont.\n PO diet started and tolerated.\n\nEndo- ssri coverage as needed\n\nHeme- stable\n\nSkin- all incisions and lacerated areas are now open to air..C&D\n several blisters noted on lateral hip & thigh in areas of incision bandages. Warm extremities with palpable pulses.\nIVC filter in situ. Compression boots in use.\n\nAssess- s/p fall with multiple trauma c/b pain issues and retained secretions....now improving.\n\nPlan- cont with current mngmnt: evaluate pain med effectiveness\n cont with aggressive pulm mngmnt\n advance activity as tolerated\n advance diet as tolerated.\n monitor cultures & follow temp trends.\n Plan for transfer in am..if bed available\n case mmngmnt for rehab\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-17 00:00:00.000", "description": "Report", "row_id": 1416719, "text": "Nursing Progress Note\nS/ pt oreinted and cooperative. pt using PCA effectively. Pt was able to use walker and with assistance from 3 people was able to pivot into bed.Pt in bed with brace on, HOB 30 degrees. pt cont to be febrile temp now 100.9 remains tachycardic with stable B/P. Pt is effectively coughing and deep breathing with sats of 97-100% on 70% facetent, Secertions are thick and tan. Good u/o. pt taking sips of clear liqs. skin on bck and buttucks .pt friends in to visit.\nA/ pt is doing well and is now cooperative with care. Did well with pivot and use of walker. Pt to be transferred to floor when bed is available\n" }, { "category": "Nursing/other", "chartdate": "2180-04-18 00:00:00.000", "description": "Report", "row_id": 1416720, "text": "T/SICU NPN 2300-0700:\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT /OPRIENTED X3: AFFECT/CONCERNS APPROPRIATE, MAE'S CONSISTENTLY TO COMMAND: EXAM . DILAUDID PCA FOR PAIN MGT W/EFFECT - USING PCA EFFECTIVELY, OFTEN RATES PAIN : ABLE TO SLEEP ON/OFF THROUGHOUT . RECEIVES ATC ATIVAN Q8HR AND GIVEN PRN DOSE X1 FOR RESTLESS AGITATION. TLSO BRACE REMAINED ON OVER PER PT REQUEST ENABLING HIM TO HAVE HOB ELEVATED.\n\nCV: HR ST->SR, NO ECTOPY NOTED, SBP 120-130'S, PERIPHERAL PULSES EASILY PALPABLE. IVF FILTER PLACED - PB'S ON FOR DVT PROPHYLAXIS.\nHCT 25.5(29) - T/SICU TEAM AWARE.\n\nRESP: LUNG SOUNDS COARSE THROUGHOUT, BASES DIMINISHED. STRONG/PRODUCTIVE COUGH EFFFORT - ABLE TO RAISE SECRETIONS AND EXPECTORATE USING YANKAUER SXN: SECRETIONS YELLOW<->TAN. O2 50% VIA COOL NEB FACE TENT - RR 16-20'S, DENIES SOB, SATS 95-100%: DESATURATES SLOWLY WHEN ON RA.\n\nGI: ABD SOFTLY DISTENDED, (+)HYPOACTIVE BS, (+)RF/NO BM. DIET ADVANCE TO CLEAR LIQUIDS, TOLERATING SM AMTS - DENIES N/V. PEPCID FOR GI PROPHYLAXIS.\n\nGU: FOLEY CATHETER PATENT DRAINING ADEQUATE HOURLY VOLUMES OF CLEAR YELLOW URINE.\n\nENDO: GLUCOSE 132/134 - COVERED PER S/S.\n\nID: TMAX 101.2->TYLENOL->100.3 - BLD CX'S FROM PREVIOUS DAY PENDING - T/SICU HO AWARE.\n\nSKIN: MIDLINE ABD INC CDI/OTA, STAPLES , NO DRAINAGE NOTED INCISION SITES TO RLE WNL, STAPLES -NO DRAINAGE. R ELBOW LAC - WNL, ANGIO SITE BENIGN.\n\nSOCIAL: NO FAMILY CONTACT THIS SHIFT.\n\nA/P: HEMODYNAMICALLY STABLE, RESPIRATORY STATUS IMPROVED, PAIN WELL MANAGED USING PCA PUMP, FOLLOW PENDING CX'S, TLSO BRACE ON AT ALL TIMES WHEN HOB ELEVATED, ENCOURAGE PO INTAKE AS TOLERATED: CONTINUE PER CURRENT PLAN OF CARE, AWAITING INPATIENT FLOOR BED AVAILABILITY FOR TXFER/ FULL SUPPORT/COMFORT/ASSIST W/ADL'S AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-15 00:00:00.000", "description": "Report", "row_id": 1416714, "text": "T/SICU NPN-\nBrief ROS:\n Pt. is awake and , . He's c/o pain most of shift today. He's gotten dilaudid for pain frequently as well as started on PCA dilaudid. He states that his pain is severe and the pain med does not help that much. He does however drift off to sleep intermittanly and is quiet then. Difficult to assess pain as pt. c/o pneumo boots equally as much as back pain. PERL.\n\n Pt. has been reletively stable this shift. Hr has been with fever this afternoon. He had a burst of ?able psvt while c/o pain . Generally rhythm has been rapid with temp but without ventricular ectopy. Skin warm and dry. Palpable periph pulses.\n\nResp- Major issue this shif. Pt. has refused to cough effectively to clear secretions, feels he's unable. NTS'd him this afternoon, got sml amt of thick yellow secretions. Stated he would cough secretions up to avoid that procedure again. Requires 100 face tent as well as NC to maintain sats of mid 90's. RR 20's. BS bilat. have rhonchi, mostly higher up anteriorly. Cont with rt CT to suction. Dsg dry and intact.\n\nGI- Belly is soft and distended. No bowel sounds heard although pt. states he's passed gas(he's thirsty). NGT to suction, funtioning adequately, sml amt of bilious secretiopns. NPO\n\nGU- Adequzte u/o via foley.\n\nID- Febrile this evening, 101.8. Got tylenol PR. Results pnd.\n\nSkin- Generally intact. DSD of mid line belly incision, rt hip x 2 and rt lateral knee, no drg noted. Rt elbow lac dsg dry, with old drg.\n\n Pt. measured for TLS brace today, to be fitted monday.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-16 00:00:00.000", "description": "Report", "row_id": 1416715, "text": "Nursing progress note\nS/ pt to angio for IVC filter.\nROS\n pt c/o pain medicated with hydromorphone PCA, pt not useing effectively requiring RN to push button, ativan given to calm pt for turning, pt became confused and agitated, pulling off O2 and pulling out NG tube. Attempted to calm pt with reassurance, without success, tried Ativan again, short duration of effectiveness with pt again becoming agitated and confused when waking, precedex gtt started for sedation as patient sats continued to drop to 75 with O2 mask off. pt napping but still waking,intermittently confused. Still requiring Hydromorphone for pain 1mg q1 hour given IVP.pt still unable to effectively use PCA pump at this time. pt moving all 4 extremities to command, with good sensation. Log rolled precautions maintained, pt in reverse trendelenberg on back.\n Initially pt HR 130 in NST, fluid of 500cc LR gien with decrease in rate to 115, IVF at 124cc hr LR. pt HR decreased to 96-110 with sedation. B/ decreased to 100-110 systolic with start of precedx gtt. Hct down to 30 this AM.\nID tmax this shift 101.8 now 100.7.\nresp- pt desatto 75-80 when mask off, pt pulling off frequently and not allowing staff to put it back onuntil precedex gtt started. Lungs sounds are coarse, cough is weak and congested, attempted to NTS once , pt pulled catheter out and became agitated. Mod amt of thick tna to yellow secretions were expectorated.\nGI- as noted NG tube out, pt abd softly distended. No bowel sounds or flatus noted,pt asking to drink frequently, swabs offered.\n pt has had adequate u/o\nskin- pt skin on back and buttucks is intact, lac on rt elbow dressing is dry and intact and not taken down, dressings on rt thigh and rt knee from ortho repair intact and dry. dresssing on angio site of left groin dry and intact, good pulses bilaterally\nsocial- both and calling for updates.\nA/ pt agitated desating with removal of O2, pt requiring sedation. Hr down with decrese in temp, fluid bolus and sedation. Brace has been ordered and to be fitted on , pt to remain on logroll prcautions. Cont with plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-16 00:00:00.000", "description": "Report", "row_id": 1416716, "text": "T/SICU NPN\nBrief ROS:\n Pt. has been confused, restless and agitated all shift. He's had varying levels of agitation, boardering on aggression. He's gotten a hold of the IV tubing on the side of the bed and pulled on tubing, almost pulling all the pumps down. He pulls at and and continuously pulls off o2. PERL. Responds to commands with squeezes and pushes. Pt. is somewhat obstructive in his care. Refuses turns or NTS. He's recieved haldol and restarted ativan today along with his dilaudid(IVP) as needed, see med sheet or care view. Restarted the precedex gtt and awaiting for positve results. Pt. himself has been frustrated with his confusion. Soft wrist restaints on pt. now. Have called for sitter if possible.\n\n Pt. has been reletively stable all shift with HR and BP. Skin warm and dry. Color gd.\n\nResp- Face tent at 100% is adequate O2 to maintain a gd sat but pt. pulls off O2 frequently. Bs are coarse throughout. Cont. to have a very weak cough only able to expecturate occ. with much encouragement. Secretions are thick yellow. RR 20's.\n\nGI- Abd is softly distended. Have not auscultated bowel sounds as yet this shift. Taking sips of soda.\n\nGU- Adequate u/o via foley.\n\nID- Temp 101.1 at present. Finished 3 doses of kefzol today.\n\nSkin- Brace (TLS) planned for monday, measured for it yesterday. Skin on back is . Sml purple looking area on gluteal fold, not broken down. Belly drsg and two rt hip drsg and , knee drsg . Rt elbow site cleaned and dsd reapplied.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-14 00:00:00.000", "description": "Report", "row_id": 1416712, "text": "TSICU Nursing Progress Note\nCare transfered in MRI. Pt scanned T and L spine, well tolerated. Dilaudid 2 mg given x2 with good effect, though short duration. Pt admitted to TSICU. Pt evaluated by orthopedics, trauma surgery and anesthesiology. Pt taken to OR with anesthesia and Dr. .\n\nNeuro - Pt x3, moves all extremites spontaneously and to command. PERRL. Head CT negative. C/o severe pain and spasms in right leg (femur fx) and back. Senstion intact to bilateral lower extremities.\n\nCV - SR to ST without ectopy. SBP 110s to 140. Peripheral pulses strong to bilateral lower extremities. CMS intact.\n\nResp - LS clear. O2 sat > 96% on 4 L NC. Sm right apical pneumo on CXR.\n\nGI - Abdomen soft, NT, + BS. Pt to OR for x-lap for free fluid in abdomen on CT.\n\nGU - Brisk uop via foley, clear yellow.\n\nSkin - Right elbow laceration sutured in ED. Bucks traction applied to right leg.\n\nA - Stable neuro exam, no focal deficits. Resp/CV stable.\n\nP - To OR for x-lap. Plan for right leg pinning . ? Neurosurg for T12 burst fx. Pain control.\n" }, { "category": "Nursing/other", "chartdate": "2180-04-15 00:00:00.000", "description": "Report", "row_id": 1416713, "text": "Nursing Progress Note\n Pt. A+Ox3, MAE with full sensation, PERRL. Agitated at times r/t the collar. Cont's in collar with strict log roll precautions.\nPain- c/o incisional and RLE pain throughout shift. Some relief of pain with PRN doses of hydromorphone, but cont's to refuse care because of severe pain.\nCV-HR 90-100s SR-ST, BP stable. Palpable distal pulses, ext's warm, +CSM.\nResp- Increasing O2 requirement overnight, with worsening breath sounds. Currently on 100% FT with 6liters NC to maintain o2sat 91-93%. Pt refuses CPT or repositioning secondary to pain.\n Pt to OR for ex-lap on . Abd soft, slightly distented. NGT to LWS, no output. NGT flushed w/ no residuals. No bowel sounds.\nRenal- Clear yellow urine via foley cath. u/o 60-200 cc/hr. IVF's cont at 125cc/hr.\nSkin- Abd. primary dsg dry and intact. Right elbow lac covered with DSD.\n Pt febrile to 101.3, MD aware.\n\nPlan- to OR today for ortho procedures to RLE. Will discuss with team need for cervical collar. Cont. to treat pain with PRN hydromorphone with pulmonary toilet as tolerated. MD to f/u with CXR for NGT placement.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2127-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420064, "text": "S/P AVR #21MM CE MAGNA PERICARDIAL VALVE ON .\n Hypoxemia\n Assessment:\n 02 sat on 4L NC 90-92% LS diminished throughout. IS to 500 with poor\n inspiratory effort and weak non-productive cough.\n Action:\n 40% cool mist face tent applied in addition to 4L NC. 20MG IV Lasix\n administered. Encouraged CBD & IS. Medicated for incisional pain.\n Response:\n 02 sat 95-97% with combined 02 delivery. (+) diuresis. LS remain\n diminished throughout with poor inspiratory effort and weak\n non-productive cough. Pt states relief from incisional pain with PO\n Percocet.\n Plan:\n Aggressive pulmonary toileting. Continue to mobilize. Continue\n diuresis. Medicate for pain as needed.\n H/O diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood glucose levels overnoc.\n Action:\n Insulin gtt per post-op protocol.\n Response:\n Blood glucose levels within normal limits per post-op protocol.\n Plan:\n Continue to monitor blood glucose levels. Continue PO Glipizide &\n Metformin XR. Advance diet.\n" }, { "category": "Nursing", "chartdate": "2127-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420065, "text": "S/P AVR #21MM PERICARDIAL VALVE ON .\n Hypoxemia\n Assessment:\n 02 sat on 4L NC 90-92% LS diminished throughout. IS to 500 with poor\n inspiratory effort and weak non-productive cough.\n Action:\n 40% cool mist face tent applied in addition to 4L NC. 20MG IV Lasix\n administered. Encouraged CBD & IS. Medicated for incisional pain.\n Response:\n 02 sat 95-97% with combined 02 delivery. (+) diuresis. LS remain\n diminished throughout with poor inspiratory effort and weak\n non-productive cough. Pt states relief from incisional pain with PO\n Percocet.\n Plan:\n Aggressive pulmonary toileting. Continue to mobilize. Continue\n diuresis. Medicate for pain as needed.\n H/O diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood glucose levels overnoc.\n Action:\n Insulin gtt per post-op protocol.\n Response:\n Blood glucose levels within normal limits per post-op protocol.\n Plan:\n Continue to monitor blood glucose levels. Continue PO Glipizide &\n Metformin XR. Advance diet.\n" }, { "category": "Nursing", "chartdate": "2127-11-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 420168, "text": "HD12\n POD 2\n 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n : Metformin ER 1000\", Glipizide 1 tab', Vasotec 5',ASA 81',\n Pravachol 5'.\n Hypoxemia\n Assessment:\n O2 sat on 4 l >95% with removal of np o2 sat 88-92. bs crackles\n ^.nonproductive cough. Is 500 with much encouragement. Cxr reveals\n atelectasis- no pnuem post ct dc.\n Action:\n Encouraged and reinforced not to remove o2. pulm toiltet with much\n encouragement. Oob x 2, ambulated to corridor outside cvicu. Lasix 20\n mg po x1. 20 meq kcl po x1.\n Response:\n Removes o2 less. Not splinting . o2 sat>95%, continues with\n nonproductive cough\n Plan:\n Continue pulm toilet, monitor comfort, .\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n 0800 glucose 143, good appetite at breakfast,12 noon glucose 258.\n awaiting transfer\n Action:\n Received metformin and glypizide, 1200 received 30 units of glargine, 8\n units of regular humalin insulin sc\n Response:\n tbd\n Plan:\n To start glargine qd in am, monitor glucose , transfer to 6 if\n glucose remains within acceptable range\n .H/O valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Sr with pvc\ns noted intermittently this shift. K 4.1 . ct dc\n Action:\n Received 20 meq kcl x1.\n Response:\n Less pvc\ns noted.\n Plan:\n Monitor comfort, vea.\n" }, { "category": "Nursing", "chartdate": "2127-11-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420233, "text": "S/P AVR #21MM PERICARDIAL VALVE ON .\n Hypoxemia\n Assessment:\n 02 sat on 4L NC 94-97% LS diminished throughout. IS to 500.\n Non-productive cough.\n Action:\n Encouraged CBD & IS. Chest PT. Medicated for incisional pain. PO Lasix\n administered as ordered.\n Response:\n LS remain diminished throughout. Pt states relief from incisional pain\n with PO Percocet. (+) diuresis.\n Plan:\n Aggressive pulmonary toileting. Continue to mobilize. Continue\n diuresis. Medicate for pain as needed.\n H/O diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood glucose levels overnoc.\n Action:\n Insulin Gtt per post-op protocol. Oral hyperglycemic agents\n administered as ordered.\n Response:\n Blood glucose levels within normal limits per post-op protocol.\n Plan:\n Continue to monitor blood glucose levels. Continue PO Glipizide &\n Metformin XR. Wean Insulin Gtt to off. Advance diet. Plan to give SQ\n Glargine this am.\n" }, { "category": "Nursing", "chartdate": "2127-11-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420337, "text": ".H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with type 2 DM- on and off insulin drip post op\n restarted oral\n meds and covered with sliding scale. p\n Action:\n Continue oral meds\ndo not hold.\n Response:\n Glu 128\ntreated with 2 units reg insulin sc. Glucose at 12 noon 206- tx\n with sliding scale- 8 units given. NP aw\n Plan:\n ? need to inc sliding scale. Also plan to progress activity in hopes of\n aiding in control of glu. NP of glucose and pt to transfer to\n floor-PA on accepting floor made aware as well\n .H/O valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt POD #3- progressing well. Deilined, started lopressor and lasix\n held in ICU for glucose control. Midline inc intact, drsg D& pt still\n has wires ? whether will be d/c prior to transfer- pt has taken po\n lopressor\nthus wires capped. Peripgeral pulses easily palp. Vvs hr\n 70\ns sr, with sbp 100-110/60. sat 95% on 2l np.\n Action:\n Pt written for transfer\nmonitor glucose\nfollow sliding scale ? need to\n inc scale-progress activity--\n Response:\n Pt and family aware of plans for transfer to floor\n Plan:\n Transfer when bed avail- progress activity- PT has seen and will cont\n to follow.\n" }, { "category": "Nursing", "chartdate": "2127-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420225, "text": "HD12\n POD 2\n 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n : Metformin ER 1000\", Glipizide 1 tab', Vasotec 5',ASA 81',\n Pravachol 5'.\n Hypoxemia\n Assessment:\n O2 sat on 4 l >95% with removal of np o2 sat 88-92. bs crackles\n ^.nonproductive cough. Is 500 with much encouragement. Cxr reveals\n atelectasis- no pneum post ct dc.\n Action:\n Encouraged and reinforced not to remove o2. pulm toiltet with much\n encouragement. Oob x 2, ambulated to corridor outside cvicu. Lasix 20\n mg po x1. 20 meq kcl po x1. cpt x1.\n Response:\n Removes o2 less. Not splinting . o2 sat>95%, continues with\n nonproductive cough\n Plan:\n Continue pulm toilet, monitor comfort, .\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n 0800 glucose 143, good appetite at breakfast,12 noon glucose 258.\n transfer cancelled.\n Action:\n Received metformin and glypizide, 1200 received 30 units of glargine, 8\n units of regular humalin insulin sc. Insulin gtt up and infusing @ 5\n units/hr with a 5 unit bolus. ^ to 6 units with glucose at 1830 127\n Response:\n Glucose 236 . with gtt glucose 127.\n Plan:\n To start glargine qd in am, monitor glucose , Transfer in am\n .H/O valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Sr with pvc\ns noted intermittently this shift. K 4.1 . ct dc\n Action:\n Received 20 meq kcl x1.\n Response:\n Less pvc\ns noted.\n Plan:\n Monitor comfort, vea.\n" }, { "category": "Nursing", "chartdate": "2127-11-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420313, "text": ".H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with type 2 DM- on and off insulin drip post op\n restarted oral\n meds and covered with sliding scale.\n Action:\n Continue oral meds\ndo not hold.\n Response:\n Glu 128\ntreated with 2 units reg insulin sc.\n Plan:\n ? need to inc sliding scale. Also plan to progress activity in hopes of\n aiding in control of glu.\n .H/O valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt POD #3- progressing well. Deilined, started lopressor and lasix\n held in ICU for glucose control. Midline inc intact, drsg D& pt still\n has wires ? whether will be d/c prior to transfer- pt has taken po\n lopressor\nthus wires capped. Peripgeral pulses easily palp. Vvs hr\n 70\ns sr, with sbp 100-110/60. sat 95% on 2l np.\n Action:\n Pt written for transfer\nmonitor glucose\nfollow sliding scale ? need to\n inc scale-progress activity--\n Response:\n Pt and family aware of plans for transfer to floor\n Plan:\n Transfer when bed avail- progress activity- PT has seen and will cont\n to follow.\n" }, { "category": "Nursing", "chartdate": "2127-11-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 419876, "text": " AVR W/#21 CE MAGNA PERICARDIAL VALVE. EZ INTUBATION. CRYSTAL\n 2.5L, 500CC CS, URINE 715CC. PEAK GLUCOSE 184, INSULIN 20U/DIVIDED\n DOSES. VANCO/CIPRO @ 0730. CLOSED CHEST CO >5.0. CPB 103\", XCP 88\". AVP\n OVER SLOWER SINUS W/PACS.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Glucose peak to 200.\n Action:\n Insulin gtt and boluses per CSRU glucose protocol.\n Response:\n Glucose dropping and currently 140.\n Plan:\n Plan to monitor glucose hourly.\n .H/O valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n CI <2 early post-op, NSR 67 underneath APacing, SBP fluctuating with\n changes in sedation.\n Action:\n LR boluses given, APacing @ 88, Neosynephrine and Nitroglycerine\n earlier to keep SBP 90-140\n Response:\n CI>2, AP over 1^st degree AVP 67, Off vasoactive drugs currently\n Plan:\n Plan to continue to monitor closely. need additional volume.\n" }, { "category": "Respiratory ", "chartdate": "2127-11-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 419872, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Plan\n Pt received from OR intubated and placed on SIMV as noted. BS clear and\n equal. Pt weaned according to fast track protocol to PSV. Pt tolerated\n well with good follow up ABG. Pt has positive cuff leak test. Pt\n extubated to cool aerosol without incident.\n" }, { "category": "Nursing", "chartdate": "2127-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 419925, "text": ".H/O diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugars 98-140 on Insulin drip\n Action:\n Drip titrated from 7units to 3units per hours per hourly blood sugars.\n Response:\n Pt has good control with insulin drip\n Plan:\n Start Lantus and Humulin insulin SC this am\n .H/O valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Good hemodynamic, Hr sinus rhythm in the 60\ns to 70\ns. adequate urine\n output. Pt on nitro briefly for bp control. Pt denies pain refusing\n pain medication\n Action:\n Pacer turned down to a demand after checking wires. Hemodynamics\n monitored through night,\n Nitro off\n Response:\n Blood pressure well controlled off drips. Pt remains with good\n hemodynamics\n Plan:\n Plan to deline this am, OOB to chair and transfer to floor. Offer pain\n med prn\n" }, { "category": "Nursing", "chartdate": "2127-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420072, "text": "S/P AVR #21MM PERICARDIAL VALVE ON .\n Hypoxemia\n Assessment:\n 02 sat on 4L NC 90-92% LS diminished throughout. IS to 500 with poor\n inspiratory effort and weak non-productive cough.\n Action:\n 40% cool mist face tent applied in addition to 4L NC. 20MG IV Lasix\n administered. Encouraged CBD & IS. Medicated for incisional pain.\n Response:\n 02 sat 95-97% with combined 02 delivery. (+) diuresis. LS remain\n diminished throughout with poor inspiratory effort and weak\n non-productive cough. Pt states relief from incisional pain with PO\n Percocet.\n Plan:\n Aggressive pulmonary toileting. Continue to mobilize. Continue\n diuresis. Medicate for pain as needed.\n H/O diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood glucose levels overnoc.\n Action:\n Insulin Gtt per post-op protocol.\n Response:\n Blood glucose levels within normal limits per post-op protocol.\n Plan:\n Continue to monitor blood glucose levels. Continue PO Glipizide &\n Metformin XR. Wean Insulin Gtt to off. Advance diet.\n" }, { "category": "Rehab Services", "chartdate": "2127-11-16 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 420187, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 427.3 /\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 76 y/o male adm \n with chest tightness x 2 days. Found to be in a-flutter and\n hypotensive with flash pulmonary edema. s/p cardiac cath which\n revealed severe aortic stenosis requiring AVR. pt needed tooth\n extraction which delayed surgery. pt now s/p AVR on with CPB\n 103 minutes and XCL 88 minutes.\n Past Medical / Surgical History: DM, AS, increased cholesterol, HTN,\n dyslipidemia, CHF, MI\n Medications: phenylephrine, mitroglycerin, morphine, ASA, metoprolol,\n glipizide, potassium\n Radiology: CXR : new patchy linear opacities R UL most likely 2'\n atelectasis, coexisting aspiration possible\n Labs:\n 27.2\n 10.0\n 123\n 17.8\n [image002.jpg]\n Other labs:\n Activity Orders: as tolerated per cardiac rehab guidelines\n Social / Occupational History: Married, retired since \n Living Environment: Lives with wife, 2 story home with bedroom on , bathrooms on both levels, + railing on stairs to , pt\n can stay on if needed, 4 STE with rail\n Prior Functional Status / Activity Level: I PTA, no AD, I ADLs, h/o 2\n falls (several years ago) on ice, drives\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert, pleasant,\n cooperative, following commands\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 78\n 106/40\n 18\n 95% 4L\n Sit\n /\n Activity\n 106/57\n 88% 3L\n Stand\n /\n Recovery\n 83\n 108/35\n 21\n 93% 4L\n Total distance walked: 150'\n Minutes: 4 min\n Pulmonary Status: Diminished BS throughout B lung fields, IS = 500 x 5\n reps, + congested, moderately strong cough\n Integumentary / Vascular: sternotomy C/D/I, epicardial pacer wires\n Sensory Integrity: intact to LT, c/o mild paresthesias in B feet 2' DM\n Pain / Limiting Symptoms: c/o discomfort in chest at incision, unable\n to rate on VAS\n Posture: rounded shoulders, slight forward head\n Range of Motion\n Muscle Performance\n WFL\n B grasp strong, B elbow flexion , B shoulder flexion \n B DF , B hip flexion > \n Motor Function: Moves all extremities in isolation\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Amb pushing w/c x 150', good step length, decreased\n cadence, otherwise unremarkable\n Rolling:\n\n\n\n\n T\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Seated: no LOB at EOB with B UE support\n Standing: no LOB with B UE support on w/c\n Education / Communication: Educated patient as to role of PT, d/c plan,\n sternal precautions.\n Communicated with RN.\n Intervention: n/a\n Other: n/a\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired ventilation\n 3.\n Impaired secretion clearance\n 4.\n Impaired knowledge of sternal precautions\n Clinical impression / Prognosis: pt is a 76 y/o male adm for AVR. pt\n presents with above noted deficits consistent with cardiac pump\n dysfunction. Anticipate that patient will be safe for d/c home after\n additional visits. pt is mobilizing extremely well. Only concern\n is patient's poor oxygenation and high O2 requirement. Ultimately, pt\n should progress with ambulation, use of IS, DB, and forced cough. pt\n would benefit from follow up with outpatient cardiac rehab in 6 weeks.\n Goals\n Time frame: 1 week\n 1.\n I sup to sit to stand\n 2.\n I amb without AD x 500' with stable HDR\n 3.\n I up/down 1 FOS with 1 rail and stable HDR\n 4.\n I state sternal precautions\n 5.\n O2 > 93% RA with activity\n 6.\n Anticipated Discharge: Home with Outpatient PT\n Treatment :\n Frequency / Duration: 1-3x/week x 1 week\n Transfer train\n Gait train pushing w/c --> no AD\n Stair train with railing\n Wean o2, DB, PLB, IS, coughing\n Patient education re: sternal precautions, cardiac rehab, walking\n program\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2127-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420063, "text": "S/P AVR W/#21 CE MAGNA PERICARDIAL VALVE ON .\n Hypoxemia\n Assessment:\n 02 sat on 4L NC 90-92% LS diminished throughout. IS to 500 with poor\n inspiratory effort and weak non-productive cough.\n Action:\n 40% cool mist face tent applied in addition to 4L NC. 20MG IV Lasix\n administered. Encouraged CBD & IS. Medicated for incisional pain.\n Response:\n 02 sat 95-97% with combined 02 delivery. (+) diuresis. LS remain\n diminished throughout with poor inspiratory effort and weak\n non-productive cough. Pt states relief from incisional pain with PO\n Percocet.\n Plan:\n Aggressive pulmonary toileting. Continue to mobilize. Continue\n diuresis. Medicate for pain as needed.\n H/O diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood glucose levels overnoc.\n Action:\n Insulin gtt per post-op protocol.\n Response:\n Blood glucose levels within normal limits per post-op protocol.\n Plan:\n Continue to monitor blood glucose levels. Continue PO Glipizide &\n Metformin XR. Advance diet.\n" }, { "category": "Physician ", "chartdate": "2127-11-16 00:00:00.000", "description": "ICU Note - CVI", "row_id": 420178, "text": "CVICU\n HPI:\n POD 2\n 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n : Metformin ER 1000\", Glipizide 1 tab', Vasotec 5',ASA 81',\n Pravachol 5'.\n Current medications:\n Acetaminophen Aspirin EC Docusate Sodium Furosemide . GlipiZIDE\n Insulin . Metoprolol Tartrate . MetFORMIN XR (Glucophage XR)\n Oxycodone-Acetaminophen . Ranitidine\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:20 AM\n PA CATHETER - STOP 08:22 AM\n CORDIS/INTRODUCER - STOP 08:23 AM\n Post operative day:\n POD#2 - AVR(#21 mm pericardial)\n 24H EVENTS:Stayed in CVICU 2'hyperglycemic control\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Furosemide (Lasix) - 09:00 PM\n Flowsheet Data as of 03:32 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 77 (69 - 88) bpm\n BP: 106/40(55) {95/30(47) - 144/66(102)} mmHg\n RR: 17 (14 - 25) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98.6 kg (admission): 94.7 kg\n Height: 69 Inch\n Total In:\n 1,307 mL\n 756 mL\n PO:\n 520 mL\n 390 mL\n Tube feeding:\n IV Fluid:\n 787 mL\n 366 mL\n Blood products:\n Total out:\n 2,085 mL\n 1,470 mL\n Urine:\n 1,735 mL\n 1,405 mL\n NG:\n Stool:\n Drains:\n Balance:\n -778 mL\n -714 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: (B)), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 123 K/uL\n 10.0 g/dL\n 77 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 100 mEq/L\n 135 mEq/L\n 27.2 %\n 17.8 K/uL\n [image002.jpg]\n 10:56 AM\n 11:02 AM\n 11:38 AM\n 11:42 AM\n 03:52 PM\n 04:10 PM\n 04:46 PM\n 10:22 PM\n 03:36 AM\n 02:20 AM\n WBC\n 13.9\n 19.4\n 16.3\n 17.8\n Hct\n 29\n 25.3\n 30.2\n 28.9\n 27.7\n 28.1\n 27.2\n Plt\n 138\n 150\n 132\n 123\n Creatinine\n 0.7\n 0.8\n 0.9\n TCO2\n 28\n 28\n 27\n 28\n Glucose\n 124\n 90\n 107\n 77\n Other labs: PT / PTT / INR:15.6/57.8/1.4, Fibrinogen:258 mg/dL, Lactic\n Acid:2.9 mmol/L, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 76yo M s/p AVR, HD stable, hypergylcemic yesterday, doing well.\n Neurologic: Neuro checks Q: 4 hr, Pain meds prn/OOB/Ambulation\n Cardiovascular: Aspirin, Beta-blocker, Statins, Start home dose of\n Pravachol\n Pulmonary: IS, cont. gentle diuresis, encourage DB &C\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, Dc foley->DTV 8h, good response to diuresis\n Hematology: stable\n Endocrine: RISS, Lantus (R), started home dose Metformin/Glipizide\n Infectious Disease:\n Lines / Tubes / Drains: Foley, Chest tube - mediastinal, Pacing wires,\n DC CTs/ foley today\n Wounds: Dry dressings\n Imaging: CXR today, : CXR: No PTX, RLL infiltrate, increased vasc.\n markings. Improved from previous\n Consults: P.T.\n ICU Care\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol,\n Comments: restarted home DM meds\n Lines:\n 20 Gauge - 05:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2127-11-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420339, "text": ".H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with type 2 DM- on and off insulin drip post op\n restarted oral\n meds and covered with sliding scale. p\n Action:\n Continue oral meds\ndo not hold. Pt off iv insulin drip at 4am\nno lantus\n given\n30 units lantus given at 1300.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 94.7 kg\n Daily weight:\n 96.9 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: CHF, MI\n Additional history: HERNIA REPAIR, TONSILLECTOMY. TYPE II DIABESTES\n (HGB A1C 6.8%) CHEST CT +SMALL BILATERAL POSTERIOR PLEURAL EFFUSIONS.\n Surgery / Procedure and date: AVR W/#21 CE MAGNA PERICARDIAL\n VALVE. EZ INTUBATION. CRYSTAL 2.5L, 500CC CS, URINE 715CC. PEAK\n GLUCOSE 184, INSULIN 20U/DIVIDED DOSES. VANCO/CIPRO @ 0730. CLOSED\n CHEST CO >5.0. CPB 103\", XCP 88\". AVP OVER SLOWER SINUS W/PACS.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:50\n Temperature:\n 97.6\n Arterial BP:\n S:127\n D:51\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 551 mL\n 24h total out:\n 1,220 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity setting:\n 0.7 mV\n Temporary atrial stimulation setting:\n 0.1 mA\n Temporary pacemaker wire condition:\n Protect &Secure\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 02:33 AM\n Potassium:\n 3.4 mEq/L\n 02:33 AM\n Chloride:\n 98 mEq/L\n 02:33 AM\n CO2:\n 30 mEq/L\n 02:33 AM\n BUN:\n 15 mg/dL\n 02:33 AM\n Creatinine:\n 0.9 mg/dL\n 02:33 AM\n Glucose:\n 122 mg/dL\n 02:33 AM\n Hematocrit:\n 26.4 %\n 02:33 AM\n Finger Stick Glucose:\n 206\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Response:\n Glu 128\ntreated with 2 units reg insulin sc. Glucose at 12 noon 206- tx\n with sliding scale- 8 units given. NP aw\n Plan:\n ? need to inc sliding scale. Also plan to progress activity in hopes of\n aiding in control of glu. NP of glucose and pt to transfer to\n floor-PA on accepting floor made aware as well\n .H/O valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Pt POD #3- progressing well. Deilined, started lopressor and lasix\n held in ICU for glucose control. Midline inc intact, drsg D& pt still\n has wires ? whether will be d/c prior to transfer- pt has taken po\n lopressor\nthus wires capped. Peripgeral pulses easily palp. Vvs hr\n 70\ns sr, with sbp 100-110/60. sat 95% on 2l np.\n Action:\n Pt written for transfer\nmonitor glucose\nfollow sliding scale ? need to\n inc scale-progress activity--\n Response:\n Pt and family aware of plans for transfer to floor\n Plan:\n Transfer when bed avail- progress activity- PT has seen and will cont\n to follow.\n" }, { "category": "Echo", "chartdate": "2127-11-14 00:00:00.000", "description": "Report", "row_id": 73654, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function. Mitral valve disease. Right ventricular function. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 09:04\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Moderate symmetric LVH. Normal regional LV systolic function. Overall\nnormal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Severe AS (AoVA <0.8cm2). Moderate (2+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\nResults were personally reviewed with the MD caring for the patient.\n\nConclusions:\nPre Bypass:\n\nThe left atrium and right atrium are normal in cavity size. No atrial septal\ndefect is seen by 2D or color Doppler. There is moderate symmetric left\nventricular hypertrophy. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the descending thoracic aorta. The number of aortic valve leaflets\ncannot be determined. The aortic valve leaflets are severely\nthickened/deformed. There is severe aortic valve stenosis (area <0.8cm2).\nModerate (2+) aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion.\n\n\nPost Bypass:\n\nThe patient is AV paced and on an infusion of phenylephrine. An aortic valve\nbioprothesis is in good postion with a peak gradient of 20mmHg. Left and right\nventricular function is preserved. The aorta is intact. The remainder of the\nexam is unchanged.\n\n\nDr. was notified in person of the results intraoperatively.\n\n\n" }, { "category": "Echo", "chartdate": "2127-11-06 00:00:00.000", "description": "Report", "row_id": 73655, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease.\nHeight: (in) 69\nWeight (lb): 214\nBSA (m2): 2.13 m2\nBP (mm Hg): 126/64\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 08:56\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Increased IVC diameter\n(>2.1cm) with 35-50% decrease during respiration (estimated RA pressure\n(10-15mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. Overall normal LVEF (>55%). TDI E/e' >15, suggesting\nPCWP>18mmHg. Transmitral Doppler and TVI c/w Grade II (moderate) LV diastolic\ndysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: lateral apex -\nhypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV hypertrophy.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Normal aortic arch diameter. No\n2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(AoVA <0.8cm2). Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR. [Due to acoustic shadowing, the severity of MR\nmay be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. The estimated right atrial pressure is\n10-15mmHg. There is mild symmetric left ventricular hypertrophy with normal\ncavity size. There is mild regional left ventricular systolic dysfunction with\ndistal lateral wall and apical hypokinesis. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Tissue Doppler imaging suggests an increased\nleft ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and\ntissue velocity imaging are consistent with Grade II (moderate) LV diastolic\ndysfunction. Right ventricular chamber size and free wall motion are normal.\nThe right ventricular free wall is hypertrophied. The aortic valve leaflets\nare severely thickened/deformed. There is severe aortic valve stenosis (area\n<0.8cm2). Mild to moderate (+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The pulmonary artery systolic pressure could\nnot be determined. There is an anterior space which most likely represents a\nfat pad.\n\nCompared with the prior study (images reviewed) of , the severity of\naortic stenosis has worsened. The left ventricle is more hypertrophies and\nmild regional wall motion abnormality is new. Left ventricular diastolic\nfunction may also have worsened.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-11-12 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1040174, "text": " 9:18 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Pre-op and dilation of aorta\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with severe aortic stenosis and question of dilated aorta on\n CXR\n REASON FOR THIS EXAMINATION:\n Pre-op and dilation of aorta\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT, \n\n HISTORY: Aortic stenosis. Preop.\n\n TECHNIQUE: Multidetector helical scanning of the chest was performed without\n intravenous contrast reconstructed as contiguous 5 and 1.25 mm thick\n axial and 5 mm thick coronal and paramedian sagittal images.\n\n There are no prior chest CTs, but today's study is read in conjunction with\n the preop chest radiograph on .\n\n FINDINGS: The aortic valve is extremely heavily calcified. Aorta is not\n enlarged and, as far as one can tell on a non-contrast examination,\n altogether normal. Small nonhemorrhagic bilateral pleural effusions layer\n posteriorly. Aside from dependent relaxation atelectasis at both bases, lungs\n are clear and the bronchial tree is patent to the subsegmental level.\n\n Central lymph nodes, though numerous are not pathologically enlarged, ranging\n up to 15 mm in the subcarinal station. There is minimal pericardial\n calcification, but no thickening or effusion. Mitral annulus is heavily\n calcified and left atrium is mildly enlarged. Atherosclerotic calcification\n is present in the major vessels of the aortic arch.\n\n IMPRESSION: Normal caliber thoracic aorta distal to heavily calcified aortic\n valve. Left atrium is mildly dilated, suggesting that mitral annulus\n calcification could be hemodynamically significant. Pericardial calcification\n is minimal. Atherosclerotic calcification noted in head and neck vessels,\n close to the aortic arch.\n\n" }, { "category": "Radiology", "chartdate": "2127-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1038838, "text": " 12:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: resolution of edema?\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year male s/p aflutter RVR and flash edema.\n REASON FOR THIS EXAMINATION:\n resolution of edema?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:44 A.M., \n\n HISTORY: Atrial flutter.\n\n IMPRESSION: AP chest compared to :\n\n Mild interstitial edema has improved since 6:30 p.m. on .\n Configuration of the trachea suggests COPD. No focal consolidation or\n appreciable pleural effusion. Heart size normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-11-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1041465, "text": " 6:13 PM\n CHEST (PA & LAT) Clip # \n Reason: eval pleural effusions\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n eval pleural effusions\n ______________________________________________________________________________\n WET READ: JKPe WED 6:36 PM\n small b/l effusions persist, likely slightyl improved from prior ct.\n lungs clear.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: S/P AVR.\n\n There are small-to-moderate bilateral pleural effusions greater on the left\n side. Cardiomegaly is mild. Sternal wires are aligned, patient is post AVR.\n There is no pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1038756, "text": " 3:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with chest pain and new atrial flutter\n REASON FOR THIS EXAMINATION:\n eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with chest pain and new atrial flutter, to rule out\n cardiopulmonary process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed. There\n is no relevant prior imaging for comparison.\n\n FINDINGS:\n\n The heart is enlarged. There is mild pulmonary vascular prominence and\n congestion. There is no pulmonary consolidation. Overall, findings are\n suggestive of mild CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-11-05 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1038797, "text": " 6:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with acute sob, decreased O2 sat\n REASON FOR THIS EXAMINATION:\n eval for failure\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH PERFORMED ON .\n\n Comparison is made with a prior study performed three hours ago.\n\n CLINICAL HISTORY: 76-year-old man with acute shortness of breath, decreased\n O2 sat. Evaluate for failure.\n\n FINDINGS: Semi-upright portable chest radiograph is obtained. There has been\n interval development of pulmonary vascular congestion with hilar engorgement.\n No pleural effusion or pneumothorax is seen. The heart remains somewhat\n enlarged. Mediastinal contour is unremarkable. There is no pneumothorax. The\n osseous structures are intact.\n\n IMPRESSION:\n\n Interval development of CHF.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2127-11-11 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1039917, "text": " 10:09 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHEST PAIN\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with severe AS going for AVR tomorrow\n REASON FOR THIS EXAMINATION:\n pre-op CXR\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 11:35 AM\n PFI: Findings compatible with severe aortic stenosis with mild amount of\n pleural effusion but no reoccurrence of pulmonary CHF.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n Preoperative chest examination on patient with severe aortic stenosis\n scheduled for aortic valve replacement.\n\n FINDINGS: There is mild cardiac enlargement; the cardiac configuration\n demonstrating a prominence of the left ventricular contour. The thoracic\n aorta is moderately widened and a prominence of the ascending aortic contour\n to the right is noted. On the lateral view, one can identify calcifications\n in the area of the aortic ostium.\n\n The pulmonary vasculature is not congested; however, the lateral view\n discloses small amounts of pleural effusion in the posterior pleural sinuses.\n\n Comparison is made with preceding chest examinations of at\n which time the patient had an episode of severe CHF.\n\n The congestive pattern has improved. Small amounts of bilateral pleural\n effusions are residuals of this previous CHF episode. No new infiltrates or\n reoccurrence of pulmonary edema on this preoperative chest examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-11-11 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1039918, "text": ", B. 10:09 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHEST PAIN\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with severe AS going for AVR tomorrow\n REASON FOR THIS EXAMINATION:\n pre-op CXR\n ______________________________________________________________________________\n PFI REPORT\n PFI: Findings compatible with severe aortic stenosis with mild amount of\n pleural effusion but no reoccurrence of pulmonary CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-11-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1040901, "text": " 11:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest performed on .\n\n HISTORY: 76-year-old man status post aortic valve replacement. Evaluate for\n pneumothorax.\n\n FINDINGS: The endotracheal tube, nasogastric tube, and Swan-Ganz catheter\n have been removed. No pneumothoraces are seen. There has been improvement of\n the perihilar opacities since the previous study. There remains a subtle left\n retrocardiac opacity. There are no signs for overt pulmonary edema. There is\n unchanged cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-11-13 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1040457, "text": " 2:47 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre-op for severe stenosis\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with severe AS going to AVR tomorrow\n REASON FOR THIS EXAMINATION:\n pre-op for severe stenosis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: Preop for aortic valve replacement.\n\n FINDINGS: Duplex evaluation was performed of bilateral carotid arteries.\n There is heterogeneous plaque in the proximal ICA bilaterally.\n\n On the right peak velocities are 93, 109 and 99 cm/sec in the ICA, CCA and ECA\n respectively. This is consistent with less than 40% stenosis.\n\n On the left peak velocities are 89, 110 and 85 cm/sec in the ICA, CCA and ECA\n respectively. This is consistent with less than 40% stenosis.\n\n There is antegrade vertebral flow bilaterally. The left vertebral artery has\n a notch waveform suggestive of possible early subclavian steal.\n\n IMPRESSION: Bilateral less than 40% carotid stenosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-11-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1040630, "text": " 11:52 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with AS s/p AVR. Please at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Status post aortic valve replacement.\n\n FINDINGS: There has been interval median sternotomy and aortic valve surgery.\n Endotracheal tube, Swan-Ganz catheter, nasogastric tube, and mediastinal\n drains are in standard position. No pneumothorax is identified.\n Cardiomediastinal contours are slightly widened, likely due to postoperative\n status of the patient. New patchy and linear opacities have developed in the\n right upper lobe, both perihilar (superior segments) and retrocardiac regions,\n and are likely due to atelectasis, although coexisting aspiration is also\n possible especially in the superior segments lower lobes.\n\n" }, { "category": "ECG", "chartdate": "2127-11-05 00:00:00.000", "description": "Report", "row_id": 166648, "text": "Sinus tachycardia. Left atrial abnormality. Prominent QRS voltage suggest left\nventricular hypertrophy. Diffuse ST-T wave abnormalities could be due to left\nventricular hypertrophy but cannot exclude ischemia. Since the previous\ntracing of -8 atrial flutter is now absent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2127-11-14 00:00:00.000", "description": "Report", "row_id": 166645, "text": "Normal sinus rhythm. Borderline voltage for left ventricular hypertrophy.\nLateral ST-T wave changes consistent with left ventricular hypertrophy.\nIntra-atrial conduction defect. Compared to the previous tracing of \nthere is no significant difference, although the ST segments are somewhat less\nimpressive.\n\n" }, { "category": "ECG", "chartdate": "2127-11-05 00:00:00.000", "description": "Report", "row_id": 166649, "text": "Atrial flutter with rapid ventricular response. Prominent QRS voltage suggest\nleft ventricular hypertrophy, although is non-diagnostic. Diffuse ST-T wave\nabnormalities - cannot exclude ischemia. Clinical correlation is suggested.\nSince the previous tracing of axis is less leftward.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2127-11-07 00:00:00.000", "description": "Report", "row_id": 166646, "text": "Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy with\nST-T wave abnormalities. Since the previous tracing of there is\nprobably no significant change.\n\n" }, { "category": "ECG", "chartdate": "2127-11-06 00:00:00.000", "description": "Report", "row_id": 166647, "text": "Sinus rhythm. Findings are as described on the previous tracing of \nexcept, the rate is now slower and ST-T wave changes are less prominent.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2127-11-05 00:00:00.000", "description": "Report", "row_id": 166881, "text": "Atrial flutter with rapid ventricular response. Prominent QRS voltage suggest\nleft ventricular hypertrophy, although is non-diagnostic. Probable left\nanterior fascicular block. Diffuse ST-T wave abnormalities - cannot exclude\nischemia. Clinical correlation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2127-11-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 419996, "text": ".H/O diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n .H/O valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2127-11-15 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 419998, "text": " POD 1\n 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n PMHx:\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n 12 noon glucose 191 . refused meal\n Action:\n Received 8 units sc regular humalin insulin sc. Oral dm agents to be\n ordered and administered.\n Response:\n To be determined\n Plan:\n Monitor glucose\n .H/O valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Stable post aortic valve replacement . pain an issue. 70 ml ct drainage\n Action:\n Swan/aline dc\nd. returned to bed . pulm toilet. 1 percocet . ct to\n remain.\n Response:\n Is to 400 with much encouragement, nonproductive cough, pain\n relieved,continues to drain serosang drainage\n Plan:\n Monitor comfort, ct drainage,transfer to 614. as per orders.\n" }, { "category": "Nursing", "chartdate": "2127-11-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420062, "text": "Hypoxemia\n Assessment:\n 02 sat on 4L NC 90-92% LS diminished throughout. IS to 500 with poor\n inspiratory effort and weak non-productive cough.\n Action:\n 40% cool mist face tent applied in addition to 4L NC. 20MG IV Lasix\n administered. Encouraged CBD & IS. Medicated for incisional pain.\n Response:\n 02 sat 95-97% with combined 02 delivery. (+) diuresis. LS remain\n diminished throughout with poor inspiratory effort and weak\n non-productive cough. Pt states relief from incisional pain with PO\n Percocet.\n Plan:\n Aggressive pulmonary toileting. Continue to mobilize. Continue\n diuresis. Medicate for pain as needed.\n H/O diabetes Mellitus (DM), Type II\n Assessment:\n Elevated blood glucose levels overnoc.\n Action:\n Insulin gtt per post-op protocol.\n Response:\n Blood glucose levels within normal limits per post-op protocol.\n Plan:\n Continue to monitor blood glucose levels. Continue PO Glipizide &\n Metformin XR. Advance diet.\n" }, { "category": "Nursing", "chartdate": "2127-11-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420053, "text": " POD 1\n 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n PMHx:\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n 12 noon glucose 191 . refused meal. Repeat glucose 213-196. ate\n crackers with po meds.\n Action:\n Received 8 units sc regular humalin insulin sc. Oral dm agents to be\n ordered and administered. Humalog 8 units given, 1730 insulin gtt\n initiated.\n Response:\n Transfer cancelled, insulin gtt with repeat glucose 144.\n Plan:\n Monitor glucose q 1 hr, encourage dinner and snack.\n .H/O valve replacement, aortic bioprosthetic (AVR)\n Assessment:\n Stable post aortic valve replacement . pain an issue. 70 ml ct drainage\n Action:\n Swan/aline dc\nd. returned to bed . pulm toilet. 1 percocet . ct to\n remain.\n Response:\n Is to 400 with much encouragement, nonproductive cough, pain\n relieved,continues to drain serosang drainage\n Plan:\n Monitor comfort, ct drainage,transfer to 614. as per orders.\n" }, { "category": "Physician ", "chartdate": "2127-11-16 00:00:00.000", "description": "Intensivist Note", "row_id": 420129, "text": "CVICU\n HPI:\n HD12\n POD 2\n 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n : Metformin ER 1000\", Glipizide 1 tab', Vasotec 5',ASA 81',\n Pravachol 5'.\n Current medications:\n Acetaminophen 3. Aspirin EC 4. Aspirin 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Dextrose 50% 8. Docusate Sodium 9. Docusate Sodium (Liquid) 10.\n Furosemide 11. Furosemide 12. GlipiZIDE\n 13. Influenza Virus Vaccine 14. Insulin 15. Magnesium Sulfate 16.\n Metoclopramide 17. Metoprolol Tartrate\n 18. MetFORMIN XR (Glucophage XR) 19. Morphine Sulfate 20. Nitroglycerin\n 21. Oxycodone-Acetaminophen\n 22. Phenylephrine 23. Pneumococcal Vac Polyvalent 24. Potassium\n Chloride 25. Propofol 26. Ranitidine\n 27. Ranitidine 28. Sodium Chloride 0.9% Flush 29. Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:20 AM\n PA CATHETER - STOP 08:22 AM\n CORDIS/INTRODUCER - STOP 08:23 AM\n --remained in ICU for insulin gtt\n Post operative day:\n POD#2 - AVR\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 36.1\nC (97\n HR: 79 (69 - 88) bpm\n BP: 102/38(54) {88/30(47) - 144/66(102)} mmHg\n RR: 18 (15 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98.6 kg (admission): 94.7 kg\n Height: 69 Inch\n CVP: 10 (10 - 10) mmHg\n Total In:\n 1,307 mL\n 196 mL\n PO:\n 520 mL\n 30 mL\n Tube feeding:\n IV Fluid:\n 787 mL\n 166 mL\n Blood products:\n Total out:\n 2,085 mL\n 890 mL\n Urine:\n 1,735 mL\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n -778 mL\n -694 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///29/\n Labs / Radiology\n 123 K/uL\n 10.0 g/dL\n 77 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 100 mEq/L\n 135 mEq/L\n 27.2 %\n 17.8 K/uL\n [image002.jpg]\n 10:56 AM\n 11:02 AM\n 11:38 AM\n 11:42 AM\n 03:52 PM\n 04:10 PM\n 04:46 PM\n 10:22 PM\n 03:36 AM\n 02:20 AM\n WBC\n 13.9\n 19.4\n 16.3\n 17.8\n Hct\n 29\n 25.3\n 30.2\n 28.9\n 27.7\n 28.1\n 27.2\n Plt\n 138\n 150\n 132\n 123\n Creatinine\n 0.7\n 0.8\n 0.9\n TCO2\n 28\n 28\n 27\n 28\n Glucose\n 124\n 90\n 107\n 77\n Other labs: PT / PTT / INR:15.6/57.8/1.4, Fibrinogen:258 mg/dL, Lactic\n Acid:2.9 mmol/L, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n D/C chest tubes\n OOB/IS\n Regular diet\n Cont metformin and glipizide and wean Insulin gtt off\n Tx to floor\n ICU Care\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 05:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2127-11-17 00:00:00.000", "description": "Intensivist Note", "row_id": 420303, "text": "CVICU\n HPI:\n 76M POD # 3 s/p AVR(#21mm pericardial) \n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n - Kept in the Unit for hyperglycemia\n - On/off insulin gtt. Off as of this morning\n Post operative day:\n POD#3 - AVR\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Furosemide (Lasix) - 08:00 PM\n Metoprolol - 08:00 PM\n Insulin - Regular - 07:52 AM\n Other medications:\n Flowsheet Data as of 08:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 79 (68 - 85) bpm\n BP: 125/50(69) {99/35(53) - 131/97(103)} mmHg\n RR: 20 (14 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96.9 kg (admission): 94.7 kg\n Height: 69 Inch\n Total In:\n 1,350 mL\n 191 mL\n PO:\n 910 mL\n Tube feeding:\n IV Fluid:\n 440 mL\n 191 mL\n Blood products:\n Total out:\n 1,740 mL\n 720 mL\n Urine:\n 1,675 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n -390 mL\n -529 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : Diminished B bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 133 K/uL\n 9.6 g/dL\n 122 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 98 mEq/L\n 134 mEq/L\n 26.4 %\n 13.6 K/uL\n [image002.jpg]\n 11:02 AM\n 11:38 AM\n 11:42 AM\n 03:52 PM\n 04:10 PM\n 04:46 PM\n 10:22 PM\n 03:36 AM\n 02:20 AM\n 02:33 AM\n WBC\n 13.9\n 19.4\n 16.3\n 17.8\n 13.6\n Hct\n 25.3\n 30.2\n 28.9\n 27.7\n 28.1\n 27.2\n 26.4\n Plt\n 138\n 150\n 132\n 123\n 133\n Creatinine\n 0.7\n 0.8\n 0.9\n 0.9\n TCO2\n 28\n 27\n 28\n Glucose\n 90\n 107\n 77\n 122\n Other labs: PT / PTT / INR:15.6/57.8/1.4, Fibrinogen:258 mg/dL, Lactic\n Acid:2.9 mmol/L, Ca:8.5 mg/dL, Mg:2.0 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Percocet PRN.\n Ambulate with PT\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue epicardial\n wires, Stable hemodynamically\n Pulmonary: IS, No issues. OOB. Pulmonary toilet\n Gastrointestinal / Abdomen: No issues\n Nutrition: Regular diet\n Renal: Foley, Keep a liter negative today\n Hematology: Stable anemia\n Endocrine: RISS, Metformine, glypizide, Lantis. Hyperglycemic\n yesterday, but much improved. Keep < 150.\n Infectious Disease: No issues\n Lines / Tubes / Drains: Pacing wires, D/c pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: CT surgery, P.T.\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n" }, { "category": "Physician ", "chartdate": "2127-11-17 00:00:00.000", "description": "ICU Note - CVI", "row_id": 420304, "text": "CVICU\n HPI:\n POD 3\n 76M s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n : Metformin ER 1000\", Glipizide 1 tab', Vasotec 5',ASA 81',\n Pravachol 5'.\n : Hyperglycemic->on/off GTT, kept in ICU, DTV~9p\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen Aspirin EC 5. Chlorhexidine Gluconate 0.12% Oral Rinse\n Docusate Sodium . Furosemide . GlipiZIDE Insulin\n . Metoclopramide Metoprolol Tartrate . MetFORMIN XR (Glucophage XR)\n Morphine Sulfate Oxycodone-Acetaminophen Potassium Chloride\n 22. Potassium Chloride 23. Pravastatin 24. Ranitidine 25. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n Post operative day:\n POD#3 - AVR\n 24H EVENTS: kept in CVICU 2' hyperglycemic control\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Furosemide (Lasix) - 08:00 PM\n Metoprolol - 08:00 PM\n Insulin - Regular - 07:52 AM\n Other medications:\n Flowsheet Data as of 08:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 79 (68 - 85) bpm\n BP: 125/50(69) {99/35(53) - 131/97(103)} mmHg\n RR: 20 (14 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 96.9 kg (admission): 94.7 kg\n Height: 69 Inch\n Total In:\n 1,350 mL\n 191 mL\n PO:\n 910 mL\n Tube feeding:\n IV Fluid:\n 440 mL\n 191 mL\n Blood products:\n Total out:\n 1,740 mL\n 720 mL\n Urine:\n 1,675 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n -390 mL\n -529 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: bibases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 133 K/uL\n 9.6 g/dL\n 122 mg/dL\n 0.9 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 98 mEq/L\n 134 mEq/L\n 26.4 %\n 13.6 K/uL\n [image002.jpg]\n 11:02 AM\n 11:38 AM\n 11:42 AM\n 03:52 PM\n 04:10 PM\n 04:46 PM\n 10:22 PM\n 03:36 AM\n 02:20 AM\n 02:33 AM\n WBC\n 13.9\n 19.4\n 16.3\n 17.8\n 13.6\n Hct\n 25.3\n 30.2\n 28.9\n 27.7\n 28.1\n 27.2\n 26.4\n Plt\n 138\n 150\n 132\n 123\n 133\n Creatinine\n 0.7\n 0.8\n 0.9\n 0.9\n TCO2\n 28\n 27\n 28\n Glucose\n 90\n 107\n 77\n 122\n Other labs: PT / PTT / INR:15.6/57.8/1.4, Fibrinogen:258 mg/dL, Lactic\n Acid:2.9 mmol/L, Ca:8.5 mg/dL, Mg:2.0 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n Assessment and Plan: 76 yo M HD stable, doing well, episodes of\n hyperglycemia requiring Insulin GTT\n Neurologic: Neuro checks Q: 4 hr, pain meds prn/OOB ambulating with PT\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue epicardial\n wires\n Pulmonary: IS, Encourage DB&cough, gentle diuresis,\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Adequate UO, fluid balance goal neg ~1L\n Hematology: stable\n Endocrine: RISS, Metformin/Glipizide\n Infectious Disease:\n Lines / Tubes / Drains: Pacing wires, DC today\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2127-11-15 00:00:00.000", "description": "Intensivist Note", "row_id": 419956, "text": "CVICU\n HPI:\n HD11\n POD 1\n 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n : Metformin ER 1000\", Glipizide 1 tab', Vasotec 5',ASA 81',\n Pravachol 5'.\n Current medications:\n Acetaminophen 3. Aspirin EC 4. Aspirin 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Dextrose 50% 8. Docusate Sodium 9. Docusate Sodium (Liquid) 10.\n Glycopyrrolate 11. Influenza Virus Vaccine\n 12. Insulin 13. Magnesium Sulfate 14. Metoclopramide 15. Morphine\n Sulfate 16. Neostigmine 17. Nitroglycerin\n 18. Oxycodone-Acetaminophen 19. Phenylephrine 20. Pneumococcal Vac\n Polyvalent 21. Potassium Chloride\n 22. Propofol 23. Ranitidine 24. Ranitidine 25. Sodium Chloride 0.9%\n Flush 26. Sucralfate 27. Vancomycin\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:30 AM\n INTUBATION - At 11:31 AM\n OR RECEIVED - At 11:47 AM\n EKG - At 12:18 PM\n ARTERIAL LINE - START 12:40 PM\n CORDIS/INTRODUCER - START 12:41 PM\n PA CATHETER - START 12:42 PM\n INVASIVE VENTILATION - STOP 05:11 PM\n EXTUBATION - At 05:15 PM\n Post operative day:\n POD#1 - AVR\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Carafate (Sucralfate) - 12:34 PM\n Insulin - Regular - 04:06 PM\n Ranitidine (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 07:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.9\nC (100.2\n HR: 89 (57 - 100) bpm\n BP: 139/55(82) {96/45(58) - 182/77(110)} mmHg\n RR: 28 (10 - 28) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n CVP: 8 (6 - 344) mmHg\n PAP: (52 mmHg) / (16 mmHg)\n CO/CI (Thermodilution): (5.19 L/min) / (2.5 L/min/m2)\n SVR: 1,033 dynes*sec/cm5\n SV: 62 mL\n SVI: 29 mL/m2\n Total In:\n 5,567 mL\n 167 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,067 mL\n 167 mL\n Blood products:\n 500 mL\n Total out:\n 2,255 mL\n 530 mL\n Urine:\n 1,135 mL\n 360 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 3,312 mL\n -363 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 470 (198 - 5,325) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 4%\n PIP: 11 cmH2O\n Plateau: 15 cmH2O\n SPO2: 93%\n ABG: 7.41/46/114/26/1\n Ve: 9.8 L/min\n Labs / Radiology\n 132 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 104 mEq/L\n 134 mEq/L\n 28.1 %\n 16.3 K/uL\n [image002.jpg]\n 10:56 AM\n 11:02 AM\n 11:38 AM\n 11:42 AM\n 03:52 PM\n 04:10 PM\n 04:46 PM\n 10:22 PM\n 03:36 AM\n WBC\n 13.9\n 19.4\n 16.3\n Hct\n 29\n 25.3\n 30.2\n 28.9\n 27.7\n 28.1\n Plt\n 138\n 150\n 132\n Creatinine\n 0.7\n 0.8\n TCO2\n 28\n 28\n 27\n 28\n Glucose\n 124\n 90\n 107\n Other labs: PT / PTT / INR:15.6/57.8/1.4, Fibrinogen:258 mg/dL, Lactic\n Acid:2.9 mmol/L\n Assessment and Plan\n Assessment and Plan:\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: OOB/IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, start lasix\n Hematology: Mild anemia --> follow QD\n Endocrine: RISS\n Infectious Disease: Periop antitbx\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op hypertension\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 12:40 PM\n Cordis/Introducer - 12:41 PM\n PA Catheter - 12:42 PM\n 16 Gauge - 12:42 PM\n 18 Gauge - 05:01 AM\n Prophylaxis:\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Disposition: Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2127-11-15 00:00:00.000", "description": "ICU Note - CVI", "row_id": 419978, "text": "CVICU\n HPI:\n POD 1\n 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n Chief complaint:\n PMHx:\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n Current medications:\n : Metformin ER 1000\", Glipizide 1 tab', Vasotec 5',ASA 81',\n Pravachol 5'\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:30 AM\n INTUBATION - At 11:31 AM\n OR RECEIVED - At 11:47 AM\n EKG - At 12:18 PM\n ARTERIAL LINE - START 12:40 PM\n CORDIS/INTRODUCER - START 12:41 PM\n PA CATHETER - START 12:42 PM\n INVASIVE VENTILATION - STOP 05:11 PM\n EXTUBATION - At 05:15 PM\n Post operative day:\n POD#1 - 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:25 AM\n Infusions:\n Other ICU medications:\n Carafate (Sucralfate) - 12:34 PM\n Insulin - Regular - 04:06 PM\n Ranitidine (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 11:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.6\nC (99.7\n HR: 83 (57 - 100) bpm\n BP: 115/60(72) {115/45(66) - 131/60(72)} mmHg\n RR: 21 (10 - 28) insp/min\n SPO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98.6 kg (admission): 94.7 kg\n Height: 69 Inch\n CVP: 10 (6 - 344) mmHg\n PAP: (44 mmHg) / (19 mmHg)\n CO/CI (Thermodilution): (5.19 L/min) / (2.5 L/min/m2)\n SVR: 1,064 dynes*sec/cm5\n SV: 61 mL\n SVI: 29 mL/m2\n Total In:\n 5,567 mL\n 559 mL\n PO:\n 100 mL\n Tube feeding:\n IV Fluid:\n 5,067 mL\n 459 mL\n Blood products:\n 500 mL\n Total out:\n 2,255 mL\n 580 mL\n Urine:\n 1,135 mL\n 410 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 3,312 mL\n -21 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 470 (198 - 5,325) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 4%\n PIP: 11 cmH2O\n Plateau: 15 cmH2O\n SPO2: 92%\n ABG: 7.41/46/114/26/1\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : Clear), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: No(t) Absent, Trace), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 132 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 104 mEq/L\n 134 mEq/L\n 28.1 %\n 16.3 K/uL\n [image002.jpg]\n 10:56 AM\n 11:02 AM\n 11:38 AM\n 11:42 AM\n 03:52 PM\n 04:10 PM\n 04:46 PM\n 10:22 PM\n 03:36 AM\n WBC\n 13.9\n 19.4\n 16.3\n Hct\n 29\n 25.3\n 30.2\n 28.9\n 27.7\n 28.1\n Plt\n 138\n 150\n 132\n Creatinine\n 0.7\n 0.8\n TCO2\n 28\n 28\n 27\n 28\n Glucose\n 124\n 90\n 107\n Other labs: PT / PTT / INR:15.6/57.8/1.4, Fibrinogen:258 mg/dL, Lactic\n Acid:2.9 mmol/L\n Assessment and Plan\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 12:43 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to other facility\n" }, { "category": "Physician ", "chartdate": "2127-11-15 00:00:00.000", "description": "ICU Note - CVI", "row_id": 419979, "text": "CVICU\n HPI:\n POD 1\n 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n Chief complaint:\n PMHx:\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n Current medications:\n Acetaminophen 3. Aspirin EC 4. Aspirin 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Dextrose 50% 8. Docusate Sodium 9. Docusate Sodium (Liquid) 10.\n Glycopyrrolate 11. Influenza Virus Vaccine\n 12. Insulin 13. Magnesium Sulfate 14. Metoclopramide 15. Morphine\n Sulfate 16. Neostigmine 17. Nitroglycerin\n 18. Oxycodone-Acetaminophen 19. Phenylephrine 20. Pneumococcal Vac\n Polyvalent 21. Potassium Chloride\n 22. Propofol 23. Ranitidine 24. Ranitidine 25. Sodium Chloride 0.9%\n Flush 26. Sucralfate 27. Vancomycin\n : Metformin ER 1000\", Glipizide 1 tab', Vasotec 5',ASA 81',\n Pravachol 5'\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:30 AM\n INTUBATION - At 11:31 AM\n OR RECEIVED - At 11:47 AM\n EKG - At 12:18 PM\n ARTERIAL LINE - START 12:40 PM\n CORDIS/INTRODUCER - START 12:41 PM\n PA CATHETER - START 12:42 PM\n INVASIVE VENTILATION - STOP 05:11 PM\n EXTUBATION - At 05:15 PM\n Post operative day:\n POD#1 - 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:25 AM\n Infusions:\n Other ICU medications:\n Carafate (Sucralfate) - 12:34 PM\n Insulin - Regular - 04:06 PM\n Ranitidine (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 11:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.6\nC (99.7\n HR: 83 (57 - 100) bpm\n BP: 115/60(72) {115/45(66) - 131/60(72)} mmHg\n RR: 21 (10 - 28) insp/min\n SPO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98.6 kg (admission): 94.7 kg\n Height: 69 Inch\n CVP: 10 (6 - 344) mmHg\n PAP: (44 mmHg) / (19 mmHg)\n CO/CI (Thermodilution): (5.19 L/min) / (2.5 L/min/m2)\n SVR: 1,064 dynes*sec/cm5\n SV: 61 mL\n SVI: 29 mL/m2\n Total In:\n 5,567 mL\n 559 mL\n PO:\n 100 mL\n Tube feeding:\n IV Fluid:\n 5,067 mL\n 459 mL\n Blood products:\n 500 mL\n Total out:\n 2,255 mL\n 580 mL\n Urine:\n 1,135 mL\n 410 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 3,312 mL\n -21 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 470 (198 - 5,325) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 4%\n PIP: 11 cmH2O\n Plateau: 15 cmH2O\n SPO2: 92%\n ABG: 7.41/46/114/26/1\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : Clear), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: No(t) Absent, Trace), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 132 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 104 mEq/L\n 134 mEq/L\n 28.1 %\n 16.3 K/uL\n [image002.jpg]\n 10:56 AM\n 11:02 AM\n 11:38 AM\n 11:42 AM\n 03:52 PM\n 04:10 PM\n 04:46 PM\n 10:22 PM\n 03:36 AM\n WBC\n 13.9\n 19.4\n 16.3\n Hct\n 29\n 25.3\n 30.2\n 28.9\n 27.7\n 28.1\n Plt\n 138\n 150\n 132\n Creatinine\n 0.7\n 0.8\n TCO2\n 28\n 28\n 27\n 28\n Glucose\n 124\n 90\n 107\n Other labs: PT / PTT / INR:15.6/57.8/1.4, Fibrinogen:258 mg/dL, Lactic\n Acid:2.9 mmol/L\n Assessment and Plan\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 12:43 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to other facility\n" }, { "category": "Physician ", "chartdate": "2127-11-15 00:00:00.000", "description": "ICU Note - CVI", "row_id": 419980, "text": "CVICU\n HPI:\n POD 1\n 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n Chief complaint:\n PMHx:\n PMH: DM, AS, ^cholesterol, Aflutter\n PSH: s/p inguinal hernia repair, ankle surgery\n Current medications:\n Acetaminophen 3. Aspirin EC 4. Aspirin 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Dextrose 50% 8. Docusate Sodium 9. Docusate Sodium (Liquid) 10.\n Glycopyrrolate 11. Influenza Virus Vaccine\n 12. Insulin 13. Magnesium Sulfate 14. Metoclopramide 15. Morphine\n Sulfate 16. Neostigmine 17. Nitroglycerin\n 18. Oxycodone-Acetaminophen 19. Phenylephrine 20. Pneumococcal Vac\n Polyvalent 21. Potassium Chloride\n 22. Propofol 23. Ranitidine 24. Ranitidine 25. Sodium Chloride 0.9%\n Flush 26. Sucralfate 27. Vancomycin\n : Metformin ER 1000\", Glipizide 1 tab', Vasotec 5',ASA 81',\n Pravachol 5'\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:30 AM\n INTUBATION - At 11:31 AM\n OR RECEIVED - At 11:47 AM\n EKG - At 12:18 PM\n ARTERIAL LINE - START 12:40 PM\n CORDIS/INTRODUCER - START 12:41 PM\n PA CATHETER - START 12:42 PM\n INVASIVE VENTILATION - STOP 05:11 PM\n EXTUBATION - At 05:15 PM\n Post operative day:\n POD#1 - 76 y/oM s/p AVR(#21mm pericardial) .\n EF:55 CR:0.8 Wt:93.6kg\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:25 AM\n Infusions:\n Other ICU medications:\n Carafate (Sucralfate) - 12:34 PM\n Insulin - Regular - 04:06 PM\n Ranitidine (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 11:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.6\nC (99.7\n HR: 83 (57 - 100) bpm\n BP: 115/60(72) {115/45(66) - 131/60(72)} mmHg\n RR: 21 (10 - 28) insp/min\n SPO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 98.6 kg (admission): 94.7 kg\n Height: 69 Inch\n CVP: 10 (6 - 344) mmHg\n PAP: (44 mmHg) / (19 mmHg)\n CO/CI (Thermodilution): (5.19 L/min) / (2.5 L/min/m2)\n SVR: 1,064 dynes*sec/cm5\n SV: 61 mL\n SVI: 29 mL/m2\n Total In:\n 5,567 mL\n 559 mL\n PO:\n 100 mL\n Tube feeding:\n IV Fluid:\n 5,067 mL\n 459 mL\n Blood products:\n 500 mL\n Total out:\n 2,255 mL\n 580 mL\n Urine:\n 1,135 mL\n 410 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 3,312 mL\n -21 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 470 (198 - 5,325) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 4%\n PIP: 11 cmH2O\n Plateau: 15 cmH2O\n SPO2: 92%\n ABG: 7.41/46/114/26/1\n Ve: 9.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : Clear), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: No(t) Absent, Trace), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 132 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 104 mEq/L\n 134 mEq/L\n 28.1 %\n 16.3 K/uL\n [image002.jpg]\n 10:56 AM\n 11:02 AM\n 11:38 AM\n 11:42 AM\n 03:52 PM\n 04:10 PM\n 04:46 PM\n 10:22 PM\n 03:36 AM\n WBC\n 13.9\n 19.4\n 16.3\n Hct\n 29\n 25.3\n 30.2\n 28.9\n 27.7\n 28.1\n Plt\n 138\n 150\n 132\n Creatinine\n 0.7\n 0.8\n TCO2\n 28\n 28\n 27\n 28\n Glucose\n 124\n 90\n 107\n Other labs: PT / PTT / INR:15.6/57.8/1.4, Fibrinogen:258 mg/dL, Lactic\n Acid:2.9 mmol/L\n Assessment and Plan\n Assessment and Plan:\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Beta-blocker\n Pulmonary: OOB/IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, start lasix\n Hematology: Mild anemia --> follow QD\n Endocrine: RISS\n Infectious Disease: Periop antitbx\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 12:43 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to other facility\n" } ]

[ { "category": "ECG", "chartdate": "2104-08-19 00:00:00.000", "description": "Report", "row_id": 208662, "text": "Technically difficult study\nSinus rhythm\nInferior infarct - age undetermined\nQT interval prolonged for rate\nLateral ST-T changes offer additional evidence of ischemia\nClinical correlation is suggested\n\n" }, { "category": "Radiology", "chartdate": "2104-08-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 928202, "text": " 5:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with ICH at OSH w/o films\n REASON FOR THIS EXAMINATION:\n bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AHPb SUN 7:18 PM\n 1. large 4cm right hemorrhage in right thalamus tracking into bilateral\n ventricular occipital horns with superimposed hydrocephalus.\n\n 2. second 5mm left convexity hemorrhage\n\n underlying neoplasm nor ischemia can be excluded and brain mr when patient's\n condition stabilizes would provide further information.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage without films, please rule out bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial head CT.\n\n FINDINGS: There is a large 4cm hemorrhagic focus lying within the right\n thalamus tracking into the ventricles with moderate amount of blood layering\n within the occipital horns (right greater than left). There is brain atrophy\n as indicated by enlarged sulci and cisterns, but the marked enlargement of the\n ventricles and appearance of the third ventricle indicates superimposed\n hydrocephalus. Fourth ventricle is within normal limits. Small amount of\n adjacent subarachnoid hemorrhage is present within the right parietal lobe.\n More chronic changes are also present including periventricular white matter\n hypodensities representing the sequela of chronic small vessel infarction, a\n previous left frontal infarct, and prior lacunar infarcts bilaterally in the\n basal ganglia.\n\n A second tiny 5 mm high density, likely hemorrhagic focus is also identified\n within the convexity of the left frontoparietal cortex. Underlying neoplasm\n and ischemia cannot be excluded for the above findings.\n\n IMPRESSION:\n 1. Large 4 cm hemorrhage centered in the right thalamus tracking into the\n occipital horns bilaterally with hydrocephalus.\n 2. 5-mm left frontoparietal convexity high density, (likely hemorrhagic)\n Underlying neoplasm and ischemia cannot be excluded. When patient's condition\n stabilizes, evaulation with MR would provide further clarification.\n\n NOTE ADDED AT ATTENDING REVIEW: I agree with the above interpretation. The\n most likely etiology for the thalamic bleed is hypertension, but correlation\n with an MR may be helpful.\n (Over)\n\n 5:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2104-08-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 928410, "text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tachypnea.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with rt thalamic hemorrhage\n\n REASON FOR THIS EXAMINATION:\n tachypnea.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old woman with right thalamic hemorrhage.\n\n COMPARISON: .\n\n FINDINGS: Since prior examination, there has been improvement in the left\n lower lobe opacity. The cardiac silhouette is enlarged with no evidence of\n pulmonary edema. The lungs are clear. The aorta is tortuous with unusual\n pattern of calcification in its arch. A CT scan with intravenous contrast is\n recommended for further characterization. Stable appearance of the right-\n sided dual chamber pacemaker with its leads projecting over the expected\n location.\n\n IMPRESSION:\n 1) Interval resolution of the left lower lobe opacity.\n 2) Unusual pattern of calcification of the aortic arch. CT scan with\n intravenous contrast is recommended for further characterization.\n\n Findings discussed with Dr. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2104-08-19 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 928459, "text": " 1:24 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: swallowing\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n\n ATTEMPTED VIDEO SWALLOW EVALUATION.\n\n FINDINGS: Due to patient's extremely lethargic condition, the patient could\n not perform a video fluoroscopic evaluation. After vigorous stimulation, 1\n teaspoon of liquid was administered. It had to be suctioned from the oral\n cavity. For further details, please consult the speech and swallow pathology\n note.\n\n" }, { "category": "Radiology", "chartdate": "2104-08-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 928224, "text": " 12:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o aspiration\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with rt thalamic hemorrhage\n REASON FOR THIS EXAMINATION:\n r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right thalamic hemorrhage. Rule out aspiration.\n\n No prior films available on PACS for comparison.\n\n PORTABLE AP CHEST RADIOGRAPH: The exam is technically limited due to patient\n rotation and exclusion of the left lateral chest from the image. The heart\n size is therefore difficult to evaluate. The aorta appears tortuous and is\n calcified. The hilar regions appear unremarkable. There is a left\n retrocardiac opacity with partial obscuration of the left hemidiaphragm. The\n right lung is clear. No right-sided pleural effusion is seen. The left\n costophrenic angle is not seen. A dual-lead pacemaker is present with atrial\n and ventricular leads projecting over the expected locations.\n\n IMPRESSION: Left retrocardiac opacity may represent aspiration pneumonia. A\n followup radiograph, ideally with a lateral view would be recommended.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2104-08-19 00:00:00.000", "description": "Report", "row_id": 1441852, "text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient had no significant events overnight. No change in neuro exam or vital signs. Pt is called out to the floor-awaiting bed at this time. No contact with family overnight.\nPLAN:\n Transfer out to floor when bed available\n Video swallow today (per plan yeseterday)\n Notify H.O. with any changes\n" }, { "category": "Nursing/other", "chartdate": "2104-08-19 00:00:00.000", "description": "Report", "row_id": 1441853, "text": "Nursing Progress Note\n Please see carevue for details of care. Minimally responsive this am, does not follow commands. PERL bilat. Remains in NSR this am. NPO, video swallow eval sched for his pm. BP elevaed to 170's, tachypneic to 40 BPM at times. Lopressor as ordered, IV lasix 20 mg and diuresed >500cc. Hydralazine x1, SBP down to 130's.\n Returned from swallow eval this pm, much less responsive, pupils sluggish to react. Family notif of patient's deteriorating condition by SICU team. - resp pattern noted this pm, maintaining sats 98-100% on 3L nc. Will continue to monitor patient condition and update family as needed with changes.\n" }, { "category": "Nursing/other", "chartdate": "2104-08-18 00:00:00.000", "description": "Report", "row_id": 1441850, "text": "NPN (NOC):\n\nPLEASE SEE FHP AND FLOWSHEET FRO DETAISL OF PMHX, HPI AND ASSESSMENT. BRIEFLY, PT IS A 76 Y/O WOMAN W/ LONGSTANDING HX OF SCHIZOPHRENIA WHO WAS LIVING IN A NURSING HOME. YESTERDAY, STAFF NOTED THAT SEH WAS LESS RESPONSIVE (NOT VERY COMMUNICATIVE AT BASELINE) W/ L SIDED NEGLECT. AT ER, CT SHOWED LG THALMIC BLEED. PER SISTER WHO IS PROXY, SHE IS DNR/DNI AND WILL NOT HAVE SURGERY. SBP'S HAVE BEEN WELL CONTROLLED, ~ 140 W/ LOPRESSOR AT 5 MG Q 6 HRS. NUERO AS ABOVE.\n" }, { "category": "Nursing/other", "chartdate": "2104-08-18 00:00:00.000", "description": "Report", "row_id": 1441851, "text": "Condition Update\nPlease see carevue for specifics.\n\nPt alert and oriented x 1. + dementia. She does not follow commands. Pupils equal and reactive. She has been afebrile. NSR. Cardiac Enzymes drawn w/ troponin <.01 Pt w/ swallow eval this afternoon. Since eval done, LS have been coarse. 3L 02 placed. MD up to eval pt. IVF infusing for hydration. Pt NPO for now. To go for video swallow ? . Integ intact.\n\nPlan: continue w/ current plan of care per micu team. Xfer to floor w/ tele when bed avail. Cont. neuro checks. Video study . IV levofloxacin for UTI. Albuterol tx's. Cardiac enzymes.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2166-01-31 00:00:00.000", "description": "Report", "row_id": 1595007, "text": "CCU Nursing Progress Note\nS-\"I have had sleep apnea for a long time\"\nO-Neuro alert and oriented but sleeping alot. Did not require sleeping aide, although asked for it. No c/o abd pain until 6am. c/o RUQ pain received dilaudid 2mg po.\nCV-Cardiogenic shock despite Dobutamine/dopamine and lasix gtt.\nMixed venous sats 38 and 41%. 8pm CO/CI/SVR 2.5/1.26/1632 on Dobutamine 10mcg/kg at 2am 2.8/1.41/1114 on Dobutamine 15mcg/kg and lasix gtt at 10mg/hr. Dobutamine increased to 17.5mcg/ and dopamine 5mcg/kg started for hypotension at 5am. SBP 77-90 HR V paced. PAD slowly decreasing to 25 and CVP <20.\nResp-LS BBR O2 sats 100% on 4l NP but sats drop to 90% with apnea.\nPt states he has a h/o sleep apnea. Apenic periods occ >40seconds.\nNo c/o SOB\nID hypothermic 93po/95R started bair hugger with temp slowly rising to 97-98po. Remains on triple abx.\nGI-Abd distended and tender. No n/v tolerating po meds, no appetite.\nNutrition consult today. PT 17.1/INR 2.0. 3 loose/soft BM's one sent for cdiff.\nGU-foley draining poorly 20cc/hr received lasix 80mg IVB with diuril 500mg po with minimal results. Lasix gtt started at 5mg/hr slowly titrated up to 15mg/hr by 6am. Still minmial results. K 3.5 received 80meq IV.\nSocial-talked to son last evening.\nA/P-Hemodynamically unstable. ?radial aline for closer monitoring.\nFollow CO/CI with changes in meds and q6-8hrs\n" }, { "category": "Nursing/other", "chartdate": "2166-01-31 00:00:00.000", "description": "Report", "row_id": 1595008, "text": "CCU NPN 7am - 7pm\nS: \" I feel nauseous.\"\nO: CVS: SBP low this morning in the 80's. Dobutamine increased initially, but BP went lower. Dobutamine is now upto 19.5 mcgs/kg. Dopamine was increased to 5 mcg/kg/min. The pt.'s pacemaker rate was increased to 80 and now the SBP is up in the 90's. C.O. and C.I. remain low. SVR was low this morning with high PAD and CVP. Later this afternoon the SVR was consistent with earlier readings. Pt. received 500 mg of po. diurel and 80 mg of IV lasix this morning. U/O has picked up this afternoon and PAD has come down. Presently the PAD is in the high 20 to low 30 range and the CVP is in the low 20's.\n\nResp: Pt. continues to have periods of apnea. O2 has been on/off. O2 sat is in the high 90's most of the time. Lung sounds are diminished at the bases.\n\nG.I.: P.t c/o abd. pain and has had lots of nausea and vomitting. PR compazine given without much effect. When BP came up .625 of droperidol was given with a much better effect. The nausea subsided and the pt. slept. Pt. has remained NPO for the day. Medications were given as the pt. could tolerate them. RUQ US needs to be read per team, before T drain placement. Total bili is 15.3. alk phos. is 127.\n\nG.U. Lasix drip continues at 15 mg/hr. Urine looks concentrated. BUN/creat are climbing.\n\nheme: HCT 33.8. PT 16.1, PTT 42.8, INR 1.8. A- line deferred secondary to coags.\n\nI.D.: temp 95 - 96. Bair hugger off for most of the day. Pt. placed back on at 5 pm. IV ampi has been D/C'd. P.O. flagyl and levoquin continue.\n\nF/E: NA 131 , cl 92. MG 2.2 mag oxide held secondary to nausea and vomitting.\n\nMental status: Pt. very discouraged today. Not feeling well and wanting to leave the hospital.\n\nComfort: Pt. received 2 mg of dilauded at 4 pm for c/o generalized pain.\n\nSkin: Pt. placed on one step bed. coccyx remains slightly reddened.\n\nA: Cholangitis complicated by chronic low output state and subsequent fluid overload.\n\nP: monitor for further nausea and vomitting, antiemetics as needed, continue diuresis with lasix, diurel, zaroxyln, continue dopa and dobutamine, EPS following for pace/defib and arrhythmias, monitor coags, lytes and LFT's, dilaudid prn pain.\n" }, { "category": "Nursing/other", "chartdate": "2166-02-03 00:00:00.000", "description": "Report", "row_id": 1595014, "text": "FAMILY C PT. DOPAMINE, SWAN DC. MSO4 GTT 2MG . BP 70 /41, V PACED RHYTHM. PT ASKING TO BE TURNED, TAKING FLUIDS . RESP IRREGULAR .SAT 96 ON 3LNP.PASSING SOFT BR STOOL. AMBER URINE VIA FOLEY .PT BE TRANSFERRED TO FLOOR. MINISTER TO SEE PT.CONTINUE COMFORT MEASURES ,EMOTIONAL SUPPORT TO FAMILY .\n" }, { "category": "Nursing/other", "chartdate": "2166-02-01 00:00:00.000", "description": "Report", "row_id": 1595009, "text": "CCU Nursing Progress Note\nS-\"I still feel nauseated\"\n \"I feel like I am going out of it\"\nO-Neuro awake and alert/oriented x3. Quiet and appears depressed, not very talkative. Having feelings of \"leaving\" and is afraid. c/o RUQ pain and is receiving dilaudid 2mg po q4hrs with fair relief.\nCV- Hypotensive most of night despite increasing dopamine 15mcg/kg and dobutamine 20mcg/kg. SBP 77-85 Hemodynamics PAD unchanged 30-33, CVP 20-23. Although CO/CI decreased overnight at 9pm Co/CI/SVR 3.3/1.67/970 but at 4:30am 2.4/1.21/1300. AT 6am pt c/o \"going out of it\" VS unchanged except RR up to 40 in between apnea. HO called to evaluate.\nResp-O2 3l np O2 sats 97-100% LS diminished in bases. Occ productive cough dark bloody sputum. Episode of SOB rr 40 shallow, along with sleep apnea up to 40 seconds.\nID temp 95 placed on Bair Hugger to warm up, temp 97 at 3am.\nGI-c/o increased pain RUQ partly releived with dilaudid po. Although also c/o nausea and receiving droperidol q6hrs IV with relief.\nAwaiting surgery to re evaluate. TB rising 15.3.\nGU-BUN/CR 71/2.5 foley draining poorly 30cc/hr amber colored. Lasix gtt at 15mg/hr and received diuril 500mg po without effect. Ho aware.\nSKin-red coccyx improved on first step mattress.\nA/P-Very poor cardiac output despite dopa/dobut\nIncrease pacer rate to 100. Discuss with pt/son regarding pt wishes about intubation/CPR.\n" }, { "category": "Nursing/other", "chartdate": "2166-02-01 00:00:00.000", "description": "Report", "row_id": 1595010, "text": "CCU NURSING 7A-7P\nS. \"I FEEL BETTER.\"\n\nO. ID: TEMP 94.5-95.8, BAIR HUGGER CONTINUES, REMAINS ON PO LEVO/FLAGYL - WBC 10.7\n\nCV: PMR REPROGRAMMED TO RATE 9O, 10:45AM VERSED .75 MG - CDV USING ICD - PT IN/OUT A-V PACING/V-PACING - W/UNDERLYING SR/ATRIAL TACHY, PMR RATE INCREASED TO 100 - 5 MIN LATER PT TO VT - RATE 170, ASSYMPTOMATIC W/BP 77/, ATTEMPTED OVERDRIVE PACING - IN/OUT VT, ICD CARDIOVERSION\nX2-3, VERSED .5MG, LIDO 75MG IVB W/O EFFECT - CONVERTED TO PMR AT 100,\nPROCAN 500MG BOLUS IV GIVEN, PROCAINAMIDE 500MG PO X 1 THEN D/C'D - PROCAINAMIDE IV GTT STARTED AT 3PM @ 1MG/MIN HR REMAINS 100-105 V-PACED/ OCCASSIONALLY A-V PACED\nL RADIAL A-LINE PLACED, BP 80-98/50-60'S THROUGHOUT DAY, DOPAMINE DECREASED TO 10 MCGS/KG, DOBUTAMINE DECREASED TO 10 MCGS/KG, MILRINONE IV STARTED AND INCREASED TO .23 MCGS/KG - PA 55-60/36-40 CVP 25 DOWN TO 19, CO/CI INCREASED TO MAX OF 4.1/2.07 SVR 956\n\nRESP: O2 SATS 96-99% ON 3L N/C, LUNGS CLEAR BUT DIMINISHED, ABG AT 5PM 78/33/7.49/26/2\n\nGI: TAKING IN SIPS GINGERALE, DENIES NAUSEA, NO VOMITTING, ABDOMEN FIRM, DISTENDED, NO STOOL\n\nGU: LASIX GTT AT 15MG - INCREASED TO 20MG/HR W/ U/O 60-100CC/HR - I/O'S +200CC TODAY, 6PM RECEIVED DIURIL 500MG PO X 1\n\nMS: AWAKE , ALERT, ORIENTED, VERY UNCOMFORTABLE, FEELING SOB, C/O BACK PAIN THIS AM DILAUDID X1 W/GOOD EFFECT, 6PM C/O GENERALIZED DISCOMFORT - REPEAT DILAUDID\n\nSOCIAL: DISCUSSED W/VARIOUS FAMILY MEMBERS ISSUE OF DNR/DNI, MOST CHILDREN IN AGREEMENT OF DNR/DNI STATUS, NOT ALL 5 SIBLINGS SPEAKING W/ONE ANOTHER, SON RAY WHO IS OLDEST IN FAMILY SPOKE W/DR RE: CODE STATUS THIS AM - HE WAS THINKING ABOUT ISSUE, PT ALSO SPOKE W/DR , WANTED TO DISCUSS W/CHILDREN PRIOR TO DECISION\n\nA: CARDIAC OUTPUT IMPROVED ON PRESENT DOSES OF MILRINONE/DOPA/DOBUTAMINE/LASIX; SLIGHT IMPROVEMNT IN DIURESIS\nDILAUDID EFFECTIVE FOE PAIN CONTROL\n\nP: MONITOR HEMODYNAMICS, ATTEMPT DIURESIS, ? WEAN DOPAMINE AS TOLERATED, DILAUDID FOR COMFORT AS ORDERED, CONTINUE DISCUSSION W/PT AND FAMILY REGARDING CODE STATUS, CONTINUE SUPPORTIVE CARE FOR PT, EMOTIONAL SUPPORT FOR FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2166-02-02 00:00:00.000", "description": "Report", "row_id": 1595011, "text": "CCU Nursing Progress Note\nS-\"I have alot of pain in my wrist (aline) and my stomach\"\nO-Neuro alert and oriented x3, quiet and withdrawn. Daughter with pt but he was not talking to her. Weak and generally uncomfortable. c/o left wrist pain (aline site) and RUQ pain receiving dilaudid 2mg q3-4hrs with fair relief.\nCV-Improved CO/CI on milrinone 4.0/2.02/900 although still hypotensive\nwith elevated PAD 38-40. Dobutamine at 10mcg/kg/dopamine increased to 17.5mcg/kg(15) and milrinone at .23 but decreased at 4am to .18mcg d/t SBP 70's. At 5am CO/CI/SVR dropped to 3.2/1.62/900. SBP 80-88/ HR 100 V paced with only one run VT 12 beats rate 150 stopped spont without ICD. Pronestyl gtt at 1mg/hr with procan/napa levels below therapeutic. Radial aline dampened and unable to draw blood.\nResp-LS decreased BS bases O2 3lnp with sats 96-98% rr 30's with sleep apnea 40seconds. Occ productive cough dark red/brown secretions.\nID on bair hugger all night, temp 95 po.\nGU-BUN/CR 74/2.8 foley urine output 30-40cc/hr on lasix gtt at 20mg/hr\nGI-taking sips of water/ginger ale with pills. No n/v or BM.\nc/o some RUQ pain with movement or coughing. Na 129\nSkin- Extremities + pitting edema, coccyx less reddened on first step mattress.\nSocial- daughter in last evening and was going to stay in waiting room last night. Son and daughter in law both called and this am said all family members will be here by 11am for a family meeting with attending and staff to discuss pt status.\nA/P-Critical condition unchanged, await for family meeting\n" }, { "category": "Nursing/other", "chartdate": "2166-02-03 00:00:00.000", "description": "Report", "row_id": 1595015, "text": "FAMILY ANGRY WHEN INFORMED OF TRANSFER TO FLOOR .SPOKE C DR ,THOUGH PRIVATE ROOM ARRANGED C COT FOR FAMILY TO STAY AND FAMILY MET C NURSING SUPERVISOR , THEY WOULD PREFER PT BE TO . DR TRYING TO ARRANGE THIS.\n" }, { "category": "Nursing/other", "chartdate": "2166-01-30 00:00:00.000", "description": "Report", "row_id": 1595005, "text": "CCU NSG ADMIT/PROGRESS NOTE/7P-7A/CARDIOMYOPATHY\n\nS- \" I WISH I COULD GET BETTER...IT ALL HURTS..\"\n\nO- PLEASE SEE EXTENSIVE ADMISSION/TRANSFER NOTES FROM MED/CCU TEAMS.\n\nIN BRIEF, THIS IS A 61 YR OLD PT WITH EXTENSIVE PMH, INCLUDING S/P MI/CABG WITH EF<20%/CARDIOMYOPATHY/CHF- WHO WAS TRANSFERED FROM OSH WITH CHOLYANGITIS ON .\nPT E COLI BACTEREMIA AND HYPOGLYCEMIA AS WELL AS ARF AND WAS TREATED WITH FLUIDS AND TRANSFERED TO 7 / FOR FURTHER TX. PT WAS STARTED ON TPN AND BECAME MORE FLUID OVERLOADED WITH RT SIDED FAILURE. HE HAS BEEN UNRESPONSIVE TO DIURETICS AND BY REPORT IS (+) 25 LB UP FROM ADMISSION WT. SURGERY EVALUATED PT AND PUT IN A T TUBE FOR DRAINAGE OF CHOLYANGITIS/ACALCULOUS CHOLYCYSTITIS AND IT BECAME DISLODGED AND WAS NOT PUT BACK IN. ULTRASOUND REVEALED GALLBLADDER WITH SLUDGE AND NO EVIDENCE OF LEAKING BILE INTO ABD/PERITONEUM. IN SETTING OF INCREASED CREATININE, WORSENED RT SIDED FAILURE/OVERLOAD AND LOW EF STATE, IT WAS DECIDED TO TRANSFER PT TO CCU EVE FOR FURTHER W/U; PA LINE; INOTROPIC THERAPY.\n\nCURRENT CCU COURSE:\n\n PT ADMITTED TO CCU 6:30 PM WITH STABLE VS-\nBP- 85/55- 95/58\nHR- 70- V PACED\nOCCASIONAL PVC'S. NO RUNS NOTED.\nALL LABS DRAWN ON ADMIT-\nINR - ELEVATED- 2.0\nPT GIVEN 2 U FFP B/T 9-10PM IN PREP FOR CORDIS INSERTION BY TEAM.\nDEFERED UNTIL THIS AM.PT IS SET UP FOR 2 MORE UNITS FFP AND HAS 2 U PRBC ON HOLD AS WELL.\nTO CHECK AM LABS RE: NEED FOR MORE FFP/VIT K IN PREP FOR TODAY'S PA LINE INSERTION.\n\n PT VERY WITH ANY EXERTION- DIMISHED BREATH SOUNDS- CLEAR- WITH CX AT BASE, YET DIM.\nO2 SATS- MID 90'S ON ROOM AIR- CURRENTLY ON 2 L NP WITH SATS- MID 90'S/\n\nGU- ATTEMPTED TO RESTART NESIRITIDE GTT AT 0.01 MCG/KG/MIN-\nNO CHANGE IN UO- REMAINS WITH DARK URINE AT 10-20CC/HOUR.\nHELD LASIX QHS, AS REPORTEDLY NOT WORKING EITHER.\nADMIT CREATININE- 2.2\n\nGI- TAKING IN SIPS LIX WITH MEDS, NO PROBLEMS,\nCOMPLAINED OF ABD DISCOMFORT AFTER SOME JUICE- REQUIRING 4 MG DILAUDID AS ORDERED.\nCURRENTLY COMFORTABLE, NO ABD/RUQ PAIN.\nMEDIUM LIX STOOL G (-).\nON PO FLAGYL FOR ? R/O C DIFF/\n\nID- AFEBRILE CURRENTLY.\nHO TO CHECK RE: RESUMING AMPI Q 6 HOUR.\nNO OTHER ANTIX CURRENTLY.\n\n PT VERY PLEASANT, YET APPEARING VERY ILL, UNCOMFORTABLE.\nASKING FOR PAIN MEDS, FOR SLEEPER- APPEARS TO BE FREE OF PAIN AND ASLEEP CURRENTLY.\nSON CALLED TO CHECK ON STATUS OF LINE.\nEXPLAINED THE PROCESS TO PT AND FAMILY MEMBER.\n\nA/P= PT ADMITTED TO CCU S/P CHOYANGITIS SEPSIS - C/B CARDOIMYOPATHY/LOW FLOW/FLUID OVERLOAD-\nHERE FOR PA LINE/INOTROPIC SUPPORT.\n\nCURRENTLY HEMODYNAMICALLY STABLE\nAFEBRILE.\nALTERED MS- PAIN R/T CHOLY- TREATED WITH DILAUDID SUCCESSFULLY.\nELEVATED COAGS TX WITH FFP IN PREP FOR LINE- TO BE DELAYED UNTIL THIS AM D/T TIME CONSTRAINTS/LATE TIME ETC.\n\nCONTINUE NISIRITIDE AS ORDERED IN HOPE OF DIURESING= PA LINE, OBTAIN #, START MILRINONE/DOBUTA GTT FOR BETTER FORWARD FLOW/UNLOADING.\nCOMFORT/PAIN CONTROL\nANTIBX AS ORDERED.\nKEEP FAMILY AND PT AWARE OF PLAN OF CARE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2166-01-30 00:00:00.000", "description": "Report", "row_id": 1595006, "text": "S. C/O OF RUQ PAIN ASKING FOR PAIN MED. DENIES SOB, CP DIZZINESS\nO. NEURO ALERT TO LETHAGIC BUT RESPONDS TO VOICE ORIENTED X3 MAE FC GIVEN 4MG PO DILAUDID AT 8AM BECAME VERY LETHAGIC BY 1500\nCARDIAC PA LINE INSERTED GIVEN 3 UFFP FOR INR 2.4 AND 1MG IV VITAMIN K, WEDGE 40, CVP 25, PAD69/39 CI 1.21, CO 2.4 SV 1333, SVRI 2645 SVO2 36, HR VPACED OCC PVC, BP 84/-98/60 NATRECOR D/C DOBUTAMINE STARTED PRESENTLY ON 10 MCG/KG/MIN, LASIX 80 MG AND 120 MG IV WITH ZAROXOYLN 10MG PO AND DIURIL 500MG PO GIVEN\nRESP ON 2LNP 02 SAT 96-100% LUNGS RUL CLEAR RLL FINE CRACKLES, LEFT CLEAR. PT BECAME DYSPNEIC RR 40'S WHEN SITTING 90 DEGREE IN BED PUT HOB DOWN WITH RESOLUTION OF SYMPTOMS, HCT 38 NA 131 K+ 4.1\nGU FOLEY URINE AMBER POOR U/O IMPROVED AFTER STARTING DOBUTAMINE ALSO GIVEN LASIX 120MG IV AND DIURIL 500MG PO AROUND 1600-1700. BUN 66 CR 2.2\nGI POOR PO INTAKE TODAY ABD FIRM DISTENDED RUG PAIN BS+ NO STOOL, US GALLBLADDER DONE\nENDOCRINE FINGERSTICK GLUCOSE 121\nSKIN INTACT\nID WBC 10.8 STARTED ON AMPICILLIN 2GM IV Q6, ON PO LEVOFLOXCIN, AND PO FLAGYL TEMP CORE 35.7\nACCESS PIC LINE RT, PA LINE RT IJ\nA. CHOLECYSTITS WITH TOTAL BODY VOLUME OVERLOAD SECONDARY TO AGGRESSIVE IVF, AND TPN,CARDIOGENIC SHOCK CHF CARDIOMYOPATHY ISCHEMIC\n\nP. TITRATE DOBUTAMINE UP TO 20 MCG/KG/MIN IF NEEDED, DIURETIC AS ORDERED, MONITOR RHYTHM\nMONITOR CI, CO, PA PRESSURES DO NOT WEDGE, BP AND U/O\nMONITOR LYTES, INR, BUN CR\n\nGIVE DILAUDID PO PRN DOSE DECREASED MONITOR CLOSELY.\nENCOURAGE PO INTAKE\n\n" }, { "category": "Nursing/other", "chartdate": "2166-02-02 00:00:00.000", "description": "Report", "row_id": 1595012, "text": "CCU NURSING 7A-7P\nS. SHAKES HEAD NO WHEN ASKED IF HE HAS PAIN\n\nO. CV: 8AM DOBUTAMINE INCREASED TO 15MCGS/KG, DOPAMINE DECREASED TO 12.5 MCGS/KG - CO 3.6, MILRINONE INCREASED TO .23 MCGS/KG\nPROCAINAMIDE AT 1MG/MIN - FAMILY MEETING AT 11:30AM - ALL 5 CHILDREN, IN-LAWS, CARDIAC FELLOW, RESIDENT, RN PRESENT - FAMILY ALL IN AGREEMENT TO DNR/DNI STATUS, IT WAS DECIDED TO SLOWLY WITHDRAW ALL MEDS; 12PM PROCAINAMIDE IV D/C'D, ALL PO MEDS D/C'D, LASIX IV GTT D/C'D AT 4PM, 1 PM ICD SETTINGS TURNED OFF AND PMR RATE DECREASED TO 90; HR CONTINUES TO BE 90 V-PACED, BP REMAINS IN 70'S/40'S ON DOPAMINE 12.5/DOBUTAMINE 15MCGS/MILRINONE .23MCGS; PA 54-60/32-38, CVP 25-27\n\nRESP: O2 SATS 95-96% ON 3L N/C, L/S CLEAR BUT DIMINISHED, RR 12-24 IRREGULAR BRETHING PATTERN W/OCCASSIONAL SHORT PERIODS APNEA\n\nNEURO: ALERT,ORIENTED X 3 BUT LETHARGIC THIS AM, TAKING ORAL MEDS, RECEIVED DILAUDID 2MG PO X 1 FOR DISCOMFORT, VERY SOMNULENT REST OF DAY, ARROUSABLE TO VOICE - STIMULATION, 5:15PM, PT SLIGHTLY MORE AWAKE, ANSWERING QUESTIONS APPROPRIATELY - STATED YES WHEN ASKED IF HE WANTED MORE PAIN MEDICATION - MSO4 2MG IV GIVEN W/GOOD EFFECT\n\nGU: FOLEY DRAINING AMBER URINE IN SMALL AMOUNTS\n\nSOCIAL: FAMILY MEETING AS NOTED ABOVE, VARIOUS FAMILY MEMBERS IN/OUT THROUGHOUT DAY, ALL APPEAR VERY SUPPORTIVE OF PT. ALTHOUGH SIBLINGS STATE THEY DO NOT ALL GET ALONG W/EACH OTHER\n\nA: END STAGE HEART FAILURE UNRESPONSIVE TO INOTROPIC THERAPY\n\nP: DNR/DNI - COMFORT MEASURES\nASSESS COMFORT LEVEL - MSO4 AS NEEDED\n? SLOWLY WEAN AND D/C DOPA/DOBUTAMINE/MILRINONE\nCONTINUE SUPPORTIVE CARE FOR PT\nPROVIDE EMOTIONAL SUPPORT AND UPDATED INFORMATION TO FAMILY MEMBERS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2166-02-03 00:00:00.000", "description": "Report", "row_id": 1595013, "text": "CCU Nursing Progress Note\nS-\"Just leave me alone\"\nO-Neuro intermittanly awake but very weak and keeps his eyes closed when talking. Appears withdrawn and angry not talking much. No c/o pain receiving MSO4 2mg IVB q4-6hrs PRN for comfort.\nCV- Remains hypotensive SBP 77-86 no change in SBP with milronone off by 12am and dobutamine off at 6am. Dopmaine remains at 12.5mcg/kg until the present bag becomes empty, then d/c. Family made pt DNR/DNI yesterday.\nResp-Labored at times with periods of sleep apnea O2 at 3lnp.\nID hypothermic c/o feeling cold most of the night with bair hugger on.\nGU-foley urine output 40-50cc/hr of dark amber urine.\nGI-taking sips of water when thirsty, no nausea. Abd firm/distended\nSkin-jaundiced and with extremites3+ edema on first step mattress.\nSocial- daughter with pt in the evening.\nA/P-comfortable with MSO4 prn, suggest possibly having a clergy person see pt.\n" }, { "category": "Echo", "chartdate": "2166-01-21 00:00:00.000", "description": "Report", "row_id": 67412, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nHeight: (in) 71\nWeight (lb): 174\nBSA (m2): 1.99 m2\nBP (mm Hg): 100/50\nStatus: Inpatient\nDate/Time: at 07:53\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is markedly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: The left ventricular cavity is moderately dilated. There is\nsevere global left ventricular hypokinesis. Overall left ventricular systolic\nfunction is severely depressed.\n\nRIGHT VENTRICLE: The right ventricular cavity is moderately dilated. Right\nventricular systolic function appears depressed.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate to\nsevere (3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Moderate to severe [3+] tricuspid regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. The left atrium is markedly dilated.\n2. The left ventricular cavity is moderately dilated. There is severe global\nleft ventricular hypokinesis with slight preservation of basal wall motion.\nSeptal flattening is present. Overall left ventricular systolic function is\nseverely depressed.\n3. The right atrium is moderately dilated. The right ventricular cavity is\nmoderately dilated. Right ventricular systolic function appears depressed.\n4. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation\nis seen.\n5. The mitral valve leaflets are mildly thickened. Moderate to severe (3+)\nmitral regurgitation is seen.\n6. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n7. In comparison to the previous report of , there is probably no\nsignificant change, except for possible mild worsening of mitral and tricuspid\nregurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2166-02-01 00:00:00.000", "description": "Report", "row_id": 143844, "text": "Atrio-ventricular paced rhythm. Compared to the previous tracing of the\nrate has accelerated and there is now tachycardia.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2166-01-28 00:00:00.000", "description": "Report", "row_id": 143845, "text": "Ventricular paced rhythm at 75 beats per minute. Probable underlying atrial\nfibrillation. There is frequent ventricular ectopy. Compared to the previous\ntracing of the underlying rhythm is now probable atrial fibrillation\nwith ventricular pacing. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2166-02-04 00:00:00.000", "description": "Report", "row_id": 143842, "text": "Regular ventricular pacing\nPacemaker rhythm - no further analysis\nAtrial rhythm uncertain\nSince previous tracing, rate decreased\n\n" }, { "category": "ECG", "chartdate": "2166-02-02 00:00:00.000", "description": "Report", "row_id": 143843, "text": "Atrio-ventricular paced rhythm with tachycardia. Compared to the previous\ntracing no significant change. Compared to the previous tracing of \nectopy is no longer present.\nTRACING #2\n\n" }, { "category": "Radiology", "chartdate": "2166-01-18 00:00:00.000", "description": "GALLBLADDER SCAN", "row_id": 750777, "text": "GALLBLADDER SCAN Clip # \n Reason: EVALUATE FOR BILE LEAKAGE.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sixty-one year old man s/p cholecystostomy tube placement after\n diagnosis of cholangitis and acalculous cholecystitis, now with abdominal pain\n after tube removal. Evaluate for bile leak.\n\n INTERPRETATION: Serial images over the abdomen show normal uptake of tracer\n into the hepatic parenchyma. The gallbladder is visualized by 90 minutes. A\n static image obtained after 3 hours shows persistent uptake within the\n gallbladder, with no significant activity within the small bowel.\n\n The lack of emptying into the small bowel after 3 hours suggests the\n possibility of obstruction.\n\n IMPRESSION: No acute cholecystitis or bile leakage. Possible obstruction of\n bile flow into the small bowel.\n /nkg\n\n\n , M.D.(dictated)\n , M.D. Approved: 4:21 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2166-01-17 00:00:00.000", "description": "T-TUBE CHOLANGIO (POST-OP)", "row_id": 750726, "text": " 4:55 PM\n T-TUBE CHOLANGIO (POST-OP) Clip # \n Reason: Please evaluate for obstruction in patient with cholangitis,\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cad, ef 10-20%, cri, liver failure congestion and\n above\n REASON FOR THIS EXAMINATION:\n Please evaluate for obstruction in patient with cholangitis, percutaneous\n cholecystostomy in place. No obstruction but T bili continues to rise,\n now 7.2.\n Thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for obstruction in patient with cholangitis,\n percutaneous cholecystostomy, rising T-bili.\n\n Procedure: 3 cc of conray was injected into the indwelling choleycystostomy\n tube.\n\n FINDINGS: On the scout film, the distal tip of the percutaneous\n cholecystostomy tube is identified. After administration of a small amount of\n Conray, free leakage of contrast into the peritoneal cavity is demonstrated.\n The catheter is not within the gallbladder.\n\n IMPRESSION: Choleycystostomy tube is not within the gallbladder. These\n findings were relayed to the Primary Team at the time of the study.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-17 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 750727, "text": " 5:21 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: Please evaluate PICC placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cad, ef 10-20%, with cholangitis, cri, liver failure.\n REASON FOR THIS EXAMINATION:\n Please evaluate PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line insertion.\n\n Comparison to earlier chest xray on shows interval insertion of a PICC\n line from the left arm which extends cephalad into the left internal jugular\n vein. Otherwise, the appearance of the chest has not changed.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-18 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 750762, "text": " 11:22 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: acalculous cholecystitis, drain no longer in gallbladder, PL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD s/p CABG, EF 10%, s/p pacer, CRI, COPD, with\n acalculous cholecystitis at OSH, bacteremia - drain placed at OSH but now out.\n PLEASE REPLACE DRAIN, FIRST IN AM . FFP to be given for procedure planned\n at 8am.\n REASON FOR THIS EXAMINATION:\n acalculous cholecystitis, drain no longer in gallbladder\n PLEASE DO FIRST IN AM \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper quadrant pain. ? of acalculus cholecystitis at\n outside hospital, inadvertent removal of percutaneous cholestostomy tube from\n gallbladder.\n\n COMPARISON: Ultrasound of .\n\n LIMITED LIVER GALLBLADDER ULTRASOUND: The liver is demonstrated to be\n enlarged, tense and congested. A right lobe 1.2 cm focus of hyperechogenicity\n is present with characteristics of hemangioma. The gallbladder is\n decompressed measuring 2.6 x 1.6 cm. No cholelithiasis or choledocholithiasis\n are demonstrated. The common bile duct measures 4 mm and there is no intra-\n or extrahepatic biliary ductal dilatation. There is no pericholecystic or\n perihepatic fluid and no ascites is demonstrated. No definite\n ultrasonographic sign is elicited, however the patient's entire right\n upper quadrant overlying the liver is tender.\n\n IMPRESSION:\n\n 1) Prominent congested liver.\n\n 2) Right lobe anterior segment hemangioma.\n\n 3) Decompressed gallbladder without significant change in wall thickness and\n without pericholecystic fluid or intra- or extrahepatic biliary ductal\n dilatation felt to be too small for placement of pigtail catheter given\n hepatic congestion and patient's coagulopathy.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 750660, "text": " 8:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 61 y/o with CHF and cholangitis r/o CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with\n REASON FOR THIS EXAMINATION:\n 61 y/o with CHF and cholangitis r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHOLANGITIS. RULE OUT CHF.\n\n PORTABLE AP CHEST RADIOGRAPH:\n\n Comparison is made to study of . There is stable left\n ventricular enlargement. There is upper zone redistribution of the pulmonary\n vasculature and indistinct pulmonary vessels on the right. There are ill-\n defined, hazy, perihilar pulmonary infiltrates and septal lines. A small\n left-sided pleural effusion is seen tracking up along the left lateral chest\n wall. No pneumothoraces are seen.\n\n Again is noted median sternotomy wires, CABG clips, and a dual chamber cardiac\n pacer. A tube is seen overlying the right upper quadrant of the abdomen.\n\n IMPRESSION:\n\n 1. Evidence for congestive heart failure.\n\n 2. Interval placement of cholecystostomy tube.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-17 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 750745, "text": " 9:24 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: picc repositioned, pulled back 9cm as per dr . please\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cad, ef 10-20%, with cholangitis, cri, liver failure.needs\n picc for frequent blood draws and iv ampi and iv flagyl, he is on mrsa prec.\n REASON FOR THIS EXAMINATION:\n picc repositioned, pulled back 9cm as per dr . please do cxr same time as\n abdominal ultrasound. please page with wet read of picc tipp thanks\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line reposition.\n\n The PICC line is again noted and has been repositioned but still extends into\n the left IJ vein terminating at the level of C6-C7. Otherwise, the appearance\n of the chest is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-17 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 750735, "text": " 7:15 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: 61 y/o with cholangitis and s/p perc GB stent on now\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with\n REASON FOR THIS EXAMINATION:\n 61 y/o with cholangitis and s/p perc GB stent on now s/p dye study\n today showing dye leaking into peritoneum. Please eval GB, ducts and postion\n of tube.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cholangitis, status post percutaneous cholecystostomy tube on\n , now with a fluoroscopy study reportedly showing dye leaking into the\n peritoneum. Evaluate gallbladder and position of tube.\n\n FINDINGS: The gallbladder is not distended. There is no evidence of\n intraluminal stones/sludge or pericholecystic fluid. There is mild gallbladder\n wall thickening, with a small amount of wall edema. The cholecystostomy tube\n is not seen within the gallbladder lumen. The common bile duct is prominent,\n measuring approximately 7 mm. This is not significantly changed from a\n previous exam of . There is no intrahepatic ductal dilatation. The\n hepatic veins are prominent, also unchanged from the previous exam. No free\n fluid is adjacent to the visualized liver.\n\n IMPRESSION:\n 1. The tip of the cholecystostomy tube not visualized within the gallbladder\n lumen.\n 2. Nondistended gallbladder with mildly thickened walls. No evidence of intra-\n luminal stones/sludge or pericholecystic fluid.\n 3. Persistent prominence of the common bile duct, compared to a previous exam\n of . No intrahepatic ductal dilatation.\n\n These findings were discussed with the house staff caring for the patient at\n the time of the examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-22 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 751032, "text": " 3:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: RUQ PAIN, S/P CHOLECYSTOSTOMY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe chf, hepatic congestion, chronic renal failure\n admitted with cholangitis from osh.\n REASON FOR THIS EXAMINATION:\n Please evaluate gallbladder in pt with possible obstruction seen on hida scan,\n rising bilirubin and increased abd pain.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Possible obstruction seen on HIDA scan, rising bilirubin and\n increased abdominal pain.\n\n COMPARISON: and .\n\n GALLBLADDER ULTRASOUND: The gallbladder is contracted and filled with sludge.\n There may be mild gallbladder wall thickening, though this is difficult to\n assess in this contracted gallbladder. There is a small amount of\n pericholecystic fluid. A son sign was elicited. The common\n duct is mildly dilated at 7 mm. The duct was imaged at the pancreatic head\n where it measured 4 mm. The pancreas was incompletely visualized.\n\n IMPRESSION: Findings consistent with acalculus cholecystitis. Dr. was\n notified of these findings by telephone.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-21 00:00:00.000", "description": "L UPPER EXTREM VEINS US LEFT", "row_id": 750925, "text": " 10:17 AM\n UPPER EXTREM VEINS US LEFT Clip # \n Reason: Please r/o thrombosis of the venous system in the left arm a\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with st. p PICC placement, now worsening left arm edema and\n pain.\n REASON FOR THIS EXAMINATION:\n Please r/o thrombosis of the venous system in the left arm after PICC placement\n 4 days ago.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P PICC placement 4 days ago, now with worsening left arm edema\n and pain.\n\n LEFT UPPER EXTREMITY ULTRASOUND: scale and Doppler son of the left\n jugular, subclavian, axillary, basilic, brachial, and cephalic veins were\n performed. The left-sided PICC catheter was identified. Normal flow,\n compressibility, and wave forms are demonstrated. Intraluminal thrombus is\n not identified.\n\n IMPRESSION: No evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-22 00:00:00.000", "description": "CVL/PICC", "row_id": 751025, "text": " 2:11 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place picc in Right arm for access for tpn, antibioti\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * CHEST AP ONLY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cad, ef 10-20%, cri, liver failure congestion and\n above\n REASON FOR THIS EXAMINATION:\n Please place picc in Right arm for access for tpn, antibiotics, iv lasix.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61 y.o. requring IV access for TPN, antibiotics.\n\n RADIOLOGISTS: Drs. and . The attending\n radiologist, Dr. , was present throughout the procedure.\n\n CONTRAST/MEDICATIONS: None.\n\n PROCEDURE/TECHNIQUE/FINDINGS: The procedure was described to the patient and\n informed consent was obtained. Son was used to access the right\n brachial vein, as no superficial veins were palpable. Son of the right\n brachial vein shows it to be widely patent and comressible. With a 21 gauge\n needle, access was gained, and an 0.018 wire was placed in the right brachial\n vein. The needle was exchanged for a 5 French Peel-Away sheath, and the 0.018\n wire from the Vaxcel kit was then advanced that the distal tip projected at\n the distal SVC. the catheter was trimmed to 40 cm and advanced over the wire\n as the sheath was simultaneously peeled away. An x-ray obtained demonstrates\n the distal tip of the PICC line to project at the distal SVC. The catheter was\n secured to the patient's skin using Stat- Lock device.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Successful placement of a 5 French double-lumen PICC line from a\n right brachial vein approach. The catheter was trimmed to 40 cm, and the\n distal tip is in the distal SVC. The line is ready for immediate use.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-21 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 750913, "text": " 7:28 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate for malignancy in pt with hemoptysis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with chf, cri, cad s/p mi, weight loss, fevers\n REASON FOR THIS EXAMINATION:\n Please evaluate for malignancy in pt with hemoptysis\n ______________________________________________________________________________\n FINAL REPORT\n CT THORAX, , with no prior Chest CT's for comparison.\n\n CLINICAL INDICATION: Weight loss and fever. Hemoptysis. Clinical suspicion\n for malignancy.\n\n Helical CT of the thorax was performed without IV or oral contrast\n administration. Images were acquired with 5 mm collimation and reconstructed\n at 5 mm intervals.\n\n Assessment of the lungs reveals mild emphysema. There is an area of\n peripheral alveolar consolidation with adjacent ground-glass opacity in the\n right lower lobe laterally, which may reflect an area of pneumonia in the\n appropriate clinical setting. Additional areas of increased opacity are noted\n in both lung bases abutting moderate-sized pleural effusions and likely\n reflect areas of passive atelectasis. Superimposed upon diffuse mild\n emphysema is a subtle ground-glass pattern in both lungs. There is a small\n focal opacity with a nodular configuration in the right upper lobe on image\n #20 of series 3, measuring only approximately 4 mm in diameter.\n\n Assessment of the airways reveals no centrally obstructing lesions.\n\n Several thickened septal lines are seen at the lung bases, and are smooth in\n caliber.\n\n Review of the soft tissue structures of the thorax demonstrates numerous\n mediastinal lymph nodes, located in multiple nodal compartments, but most\n prominent in the paratracheal, precarinal and prevascular regions. The vast\n marjority of the nodes measure less than 1 cm in greatest short axis\n dimension, but a dominant precarinal node is approximately 13 mm in short axis\n dimension. Additional nodes are observed in the subcarinal region. No\n significant hilar lymph node enlargement is observed. The heart is mildly\n enlarged. No pericardial effusion is identified. As mentioned there are\n moderate-sized dependent pleural effusions bilaterally.\n\n Imaging of the upper portion of the abdomen demonstrates the presence of a\n small amount of ascites as well as diffuse stranding within the mesentery and\n in the retroperitoneum. The imaged portion of the liver reveals no focal\n abnormalities on this noncontrast study. The spleen is unremarkable. The\n imaged portions of the kidneys reveal no suspicious renal masses. The adrenal\n glands demonstrate slight thickening on the left without discrete mass.\n Several small lymph nodes are seen throughout the mesentery and\n retroperitoneum. Please note that the liver and kidneys as well as the\n pancreas are incompletely imaged on this study. Note is made of edematous\n (Over)\n\n 7:28 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate for malignancy in pt with hemoptysis\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n changes within the soft tissue structures of the chest and abdominal wall.\n There is also marked bilateral gynecomastia. An ICD is in place with leads in\n the right atrium and right ventricle.\n\n Review of the skeletal structures of the thorax reveals evidence of previous\n sternotomy. No suspicious lytic or blastic lesions are observed.\n\n IMPRESSION: 1) Peripheral area of consolidation in the right lower lobe,\n which most likely represents an area of pneumonia given the provided history\n of fever. In the appropriate clinical setting, pulmonary infarction would be\n an additional consideration, and dedicated CT angiography study could be\n performed for more complete assessment of the pulmonary vessels if this is a\n clinical consideration.\n 2) Less than 5 mm diameter right upper lobe lung nodule, which could be\n inflammatory, post inflammatory, or could potentially represent an early focus\n of neoplasm. Three month follow up CT may be helpful given risk factor of\n emphysema.\n 3) Numerous mediastinal lymph nodes, of uncertain etiology. Enlarged nodes\n can accompany congestive heart failure, but are not specific for this process.\n Follow up CT would also be helpful to document resolution of the lymph nodes\n (medical treatment of CHF prior to repeat CT scan would be helpful in this\n regard).\n 4) Diffuse ground-glass pattern, scattered thickened septal lines, and\n bilateral moderate-sized pleural effusions, all likely due to congestive heart\n failure.\n 5) Ascites and mild anasarca.\n 6) Diffuse stranding of mesentery in several small mesenteric lymph nodes.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-30 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 751649, "text": " 1:47 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: PT presentning with increasing RUQ abdominal pain. s/p acute\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe chf, hepatic congestion, chronic renal failure\n admitted with cholangitis from osh.\n REASON FOR THIS EXAMINATION:\n PT presentning with increasing RUQ abdominal pain. s/p acute cholecystitis with\n drainiage catheter for drainage, which fell out and was not replaced. Please\n evaluate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61 year old man with severe CHF, hepatic congestion, chronic\n renal failure, admitted with cholangitis from outside hospital. Drainage\n catheter fell out and was not replaced.\n\n FINDINGS: A right-sided pleural effusion is noted. Several small hyperechoic\n lesions are seen in the liver, consistent with hemangiomas. The hepatic veins\n are dilated. Normal hepatopetal flow is seen in the portal vein. The common\n bile duct is not dilated, measuring 7 mm, taking into account the patient's\n age. The gallbladder wall is thickened, measuring 5 cm, however, the\n gallbladder is collapsed. A small amount of ascites is noted. The visualized\n portions of the head and body of the pancreas are unremarkable.\n\n IMPRESSION:\n\n 1. Son findings are consistent with right heart failure with hepatic\n congestion, right-sided pleural effusion and small amount of ascites.\n\n 2. Gallbladder wall thickening in the absence of gallbladder dilatation is\n also felt to be due to right heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-01-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 751376, "text": " 11:08 AM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for chf in pt with decreased o2 sats\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p cholangitis with liver failure congestion, not\n tolerating diuresis\n REASON FOR THIS EXAMINATION:\n Please evaluate for chf in pt with decreased o2 sats\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Decreased oxygen saturation. CHF.\n\n COMPARISONS: .\n\n An ICD remains in place with right atrial and right ventricular leads. The\n heart demonstrates left ventricular configuration and is mildly enlarged.\n There remains upper zone vascular redistribution and perihilar haziness, as\n well as areas of patchy increased opacity in the right perihilar region and in\n both lower lobes. There are small bilateral pleural effusions present, with\n the left effusion apparently new in the interval and the right effusion not\n significantly changed. A left PICC line has been removed in the interval and\n replaced with a right PICC line, which terminates in the superior vena cava.\n\n IMPRESSION:\n 1) Persistent findings suggestive of CHF. Additional multifocal patchy lung\n opacities in the right perihilar region, and in both lung bases likely reflect\n asymmetric edema, although underlying infection is also possible in the\n appropriate clinical setting.\n 2) Small left pleural effusion, new in the interval. No significant changes\n of small right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 751653, "text": " 2:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P swan ganz catheter placement. Please evaluate for cathet\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD, HTN, CHF, acute cholecystitis\n REASON FOR THIS EXAMINATION:\n S/P swan ganz catheter placement. Please evaluate for catheter placement,\n pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: SWAN-GANZ PLACEMENT.\n\n CHEST AP: Comparison is made to the prior film dated . There is\n interval placement of a Swan-Ganz catheter, with the tip located in one of the\n branches of right pulmonary artery. The Swan-Ganz catheter could be pulled\n back 6 cm for optimal position. Note is also made of a right-sided subclavian\n line, with the tip in the mid SVC in satisfactory position. No evidence of\n pneumothorax. Heart is again noted to demonstrate slight LV enlargement, with\n mild upper zone redistribution. Note is also made of multiple focal patchy\n opacities in the right perihilar region, suggestive of possible asymmetric\n edema. ____ findings are consistent with mild CHF. The left CP angle is not\n included in the study and cannot be assessed. The right CP angle is clear.\n No significant change otherwise from the prior study.\n\n IMPRESSION:\n\n 1. Interval placement of Swan-Ganz catheter with the tip in one of the\n branches of the right pulmonary artery. The Swan-Ganz catheter could be\n pulled back 6 cm for optimal position. No evidence of pneumothorax.\n\n 2. Persistent finding suggestive of CHF, unchanged from the prior study.\n\n" }, { "category": "Radiology", "chartdate": "2166-01-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 751695, "text": " 7:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for swan tip, air space disease\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD, HTN, CHF, acute cholecystitis\n REASON FOR THIS EXAMINATION:\n eval for swan tip, air space disease\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF, acute cholecystitis, Swan-Ganz catheter placement.\n\n AP SEMI-UPRIGHT CHEST: Left AICD device projects, its leads over the right\n atrium and ventricle. Compared to the exam one day previously, the Swan-Ganz\n catheter has been partially withdrawn, with its tip terminating in the right\n main pulmonary artery. The heart is enlarged. The patient is s/p median\n sternotomy and CABG. There is persistent perihilar patchy densities\n consistent with failure. The right costophrenic angle is not included on this\n exam. There is a small left pleural effusion.\n\n IMPRESSION: Swan-Ganz tip in good position. Perihilar interstitial edema and\n small left pleural effusion are consistent with CHF.\n\n" } ]

[ { "category": "Echo", "chartdate": "2168-11-02 00:00:00.000", "description": "Report", "row_id": 102451, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 140/82\nStatus: Inpatient\nDate/Time: at 10:33\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nLEFT VENTRICLE: There is severe regional left ventricular systolic\ndysfunction.\n\nRIGHT VENTRICLE: There is mild global right ventricular free wall hypokinesis.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild to moderate\n(+) mitral regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is severe regional left\nventricular systolic dysfunction with severe global hypokinesis, paradoxical\nseptal motion and akinesis of the inferoposterior wall. . There is mild global\nright ventricular free wall hypokinesis. The aortic valve leaflets are mildly\nthickened. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild to moderate (+) mitral regurgitation is seen. There\nis no pericardial effusion.\n\nCompared with the prior report (tape unavailable) of , there is no\nsignificant change\n\n\n" }, { "category": "Echo", "chartdate": "2168-10-24 00:00:00.000", "description": "Report", "row_id": 102364, "text": "PATIENT/TEST INFORMATION:\nIndication: 5 Month f/u Chest pain. Coronary artery disease.\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 146/86\nStatus: Outpatient\nDate/Time: at 13:00\nTest: TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity is mildly dilated. There is severe\nglobal left ventricular hypokinesis. Overall left ventricular systolic\nfunction is severely depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is moderate\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. The left ventricular cavity is mildly dilated. There is severe global left\nventricular hypokinesis with some preservation of basal anterior and lateral\nwall motion. Overall left ventricular systolic function is severely depressed.\n3. The aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n4. In comparison to the previous report of , LV function and wall motion\nhave worsened.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2168-10-28 00:00:00.000", "description": "Report", "row_id": 1378141, "text": " update report 7p to 7a:\nNeuro: alert and oriented x 3, following commands correctly, mae.\nCardiac: nsr in the 80's, bp's all wnl, a-febrile, good pedial pulses, +1 edema on legs and arms. 2a and 2 v-wires. hct drop this am and transfused with 1 unit prbc's. good cvp's and good ci's and co's.\nSkin: chest with dsd that is cdi, right leg ace with dsd that is cdi, ct site with dsd that is cdi.\nResp: lung sounds are diminished in bases bilat, no leak in ct system, on 2L nc satting at 98%.\nGi/Gu: tolerating po's, hypoactive bowel sounds, making low amounts of urine md aware and will await for blood to infuse and re-eval u/o status.\nPain: morphine iv and percocets given for pain.\nPlan: monitor hct, monitor u/o, monitor hr,rhythm and bp's, wean milrinone gtt, trans to floor when stable.\n" }, { "category": "Nursing/other", "chartdate": "2168-10-27 00:00:00.000", "description": "Report", "row_id": 1378140, "text": "NSG: ADMISSION NOTE TO \nPT AT 1120 AM S/P CABG X 4. PT RECIEVED ON PROPOFOL,MILRINONE AND NEO GTT'S.\n\nNEURO: PT SEDATED ON PRPOFOL. PROPOFOL GTT TURNED TO OFF AT 1330 AND REVERSALS GIVEN. PT SLOW TO WAKE. PT CURRENTLY ABLE TO FOLLOW COMMANDS. MAE SPOTANEOUSLY. PT ALERT AND ORIENATED X3.\n\nCV: PT REMAINS NSR/1ST DEGREE AV BLOCK. HR 70-90'S. PT WITH LBBB (SINCE ). MAP 60-90. SBP 80-150'S. NEO AND NITRO GTT'S TITRATED TO KEEP MAP 60-90. (SEE FLOWSHEET) CURRENTLY OFF NEO AND NITRO GTT'S. PT ON MILRINONE GTT AT 0.2 MCG/KG/MIN (EF ~ 20%). CI 2.22-2.98. PT 2 A WIRES AND 2 V WIRES -> A AND V WIRES SENSING INAPPROPIATELY. K REPLACED. PP BY DOPPLER.\n\nRESP: PT EXTUBATED AT 1700 -> PLACED ON 40 % FACE TENT. SEE FLOWSHEETS FOR ABG'S. O2 SATS 98-100%. PT WITH CT X 3 (NO AIRLEAK NOTED). 1ST HR CT OUTPUT 120 CC (ACT DONE AT THIS TIME 130 -> PT WITH 50 MG PROTAMINE) WHEN PT TURNED SIDE TO SIDE -> CT WITH 105 CC OUTPUT. COAGS ELVATED -> TREATED WITH 2 UNITS FFP. CT HAVE SINCE SLOWED TO 10-40 CC/HR.\n\nGI/GU: BS ABSENT. OGT WHEN PT WAS EXTUBATED. FOLEY TO GRAVITY DRAINING LIGHT YELLOW URINE. UO ADEQUATE.\n\nENDO: PT STARTED ON INSULIN GTT D/R ELVATED GLUCOSE. INSULIN GTT TITRATED TO KEEP GLUCOSE AT GOAL 80-120 (SEE FLOWSHEET)\n\nSOCIAL: FAMILY INTO SEE PT AND AS TO POC. FAMILY UPDATED BY DR. .\n\nPLAN: CONTINUE ON MILRINONE GTT, PULM TOLIET, PAIN COTNROL, MONITOR HCT/LYTES/GLUCOSE, TITRATED INSULIN GTT TO KEEP BS 80-120.\n" }, { "category": "ECG", "chartdate": "2168-11-02 00:00:00.000", "description": "Report", "row_id": 291488, "text": "Atrial fibrillation. Since the previous tracing of the rhythm is once\nmore atrial fibrillation. There is otherwise, no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2168-11-01 00:00:00.000", "description": "Report", "row_id": 291489, "text": "Since the previous tracing, the rhythm is now sinus. P-R interval is at the\nupper limits of normal. There is otherwise, no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2168-11-01 00:00:00.000", "description": "Report", "row_id": 291490, "text": "Atrial fibrillation. No significant change compared to the previous tracing\nof .\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2168-10-31 00:00:00.000", "description": "Report", "row_id": 291491, "text": "Atrial fibrillation with a rapid ventricular response. Compared to the previous\ntracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2168-10-29 00:00:00.000", "description": "Report", "row_id": 291492, "text": "Atrial fibrillation with a moderate ventricular response. Compared to the\nprevious tracing of T wave inversion, previously recorded in lead V6,\nis now absent. Otherwise, no diagnostic change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2168-10-29 00:00:00.000", "description": "Report", "row_id": 291493, "text": "Atrial fibrillation with a moderate ventricular response. Compared to the\nprevious tracing of atrial fibrillation has appeared and there is a\nreturn to the more prominent T wave inversion in leads II, III and aVF as\npreviously recorded on and new T wave inversion in lead V6. Rule out\ninferolateral ischemic process. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2168-10-28 00:00:00.000", "description": "Report", "row_id": 291494, "text": "Sinus rhythm. The P-R interval is 0.20. QS deflections in leads VI-V2 with\ndelayed precordial R wave progression. Low limb lead voltage. Inferior\nmyocardial infarction with less prominent T wave inversion in II, III, aVF\nconsistent with a recent ischemic process. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2168-10-27 00:00:00.000", "description": "Report", "row_id": 291495, "text": "Probable normal sinus rhythm although P waves difficult to assess\nIntraventricular conduction delay\nQS configuration in leads V1-V5 could be due in part to intraventricular\nconduction delay but consider also prior anteroseptal myocardial infarction\nST-T wave abnormalities - cannot exclude ischemia\nSince previous tracing of : altered pattern of intraventricular\nconduction delay and further ST-T wave changes seen\n\n" }, { "category": "ECG", "chartdate": "2168-10-26 00:00:00.000", "description": "Report", "row_id": 291719, "text": "Sinus rhythm, rate 53. Since the previous tracing of no ectopy is\nnoted. Positional changes are seen over the lateral precordium.\n\n" }, { "category": "ECG", "chartdate": "2168-10-24 00:00:00.000", "description": "Report", "row_id": 291720, "text": "Sinus bradycardia with atrial premature beats. P-R interval 0.20. Left\nbundle-branch block. Since the previous tracing of the rate has slowed\nand the QRS complexes have widened.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2178-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1174676, "text": " 1:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval progression\n Admitting Diagnosis: FEVER;TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with hypoxemic respiratory failure\n REASON FOR THIS EXAMINATION:\n Interval progression\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 2:45 A.M. ON \n\n HISTORY: 28-year-old woman with hypoxemic respiratory failure.\n\n IMPRESSION: AP chest compared to through 30:\n\n Slight increase in heart size and vascular caliber since suggests\n volume dependent cardiac decompensation, which may also explain increasing\n left pleural effusion. More widespread pulmonary opacification which improved\n between and persists, with particularly severe\n consolidation at the base of the left lung. This needs to be followed to\n exclude nosocomial pneumonia.\n\n ET tube in standard placement. Nasogastric tube ends in the mid stomach.\n\n Of note there may be nodular, bony coalition of the right first and second\n ribs which could interfere with a subclavian line insertion.\n\n" }, { "category": "Radiology", "chartdate": "2178-01-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1174490, "text": " 2:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from prior\n Admitting Diagnosis: FEVER;TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n change from prior\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:21 A.M. \n\n HISTORY: Respiratory distress.\n\n IMPRESSION: AP chest compared to :\n\n Generalized pulmonary consolidation has improved, though some of this may be\n due to increased positive pressure ventilation since lung volumes are slightly\n larger. There is, however, new small left pleural effusion, partially\n visceral and loss of volume in the left lower lung. I have discussed with Dr.\n the possibility of acute pulmonary embolus. The heart size is normal.\n ET tube is in standard placement and the nasogastric tube ends in the stomach\n but needs to be advanced several centimeters to move all the side ports well\n below the GE junction. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-01-23 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1175421, "text": " 2:38 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 46cm left picc. tiP?\n Admitting Diagnosis: FEVER;TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n 46cm left picc. tiP?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n left-sided PICC line. The tip of the line projects over the right atrium, the\n line should be pulled back by 4-5 cm to ensure correct position in the mid\n SVC.\n\n There is no evidence of complications, notably no pneumothorax.\n\n Unchanged right apical rib abnormality.\n\n On today's image, the lungs are clear, there is no evidence of pleural\n effusions. Normal size of the cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-01-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1174342, "text": " 3:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Worsening infiltrates?\n Admitting Diagnosis: FEVER;TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with profound hypoxemia, cough with sputum, fevers\n REASON FOR THIS EXAMINATION:\n Worsening infiltrates?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: Study of .\n\n FINDINGS: Widespread bilateral alveolar opacities with relative sparing of\n the extreme apices have slightly progressed in the interval and are\n accompanied by small pleural effusions. Considering infectious symptoms, this\n could represent a rapidly progressive pneumonia possibly complicated by ARDS.\n Differential diagnosis is broad, and also includes various causes of pulmonary\n edema and pulmonary hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2178-01-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1174118, "text": " 11:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? cause for infection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with flu-like symptoms for past several days, high fever,\n tachycardic in ED.\n REASON FOR THIS EXAMINATION:\n ? cause for infection\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single AP upright portable view.\n\n CLINICAL INFORMATION: 28-year-old female with history of flu-like symptoms\n for past several days, high fever, tachycardic.\n\n COMPARISON: None.\n\n FINDINGS: Single frontal view of the chest was obtained. Relative hazy\n opacity overlying the left hemithorax is likely technical as the adjacent soft\n tissue is also more dense as compared to the right. No definite focal\n consolidation, pleural effusion, or pneumothorax is seen. Cardiac and\n mediastinal silhouettes are unremarkable.\n\n While findings may be due to position, there may be subtle chronic deformity\n of the anterior right first and second ribs, which may be congenital.\n\n IMPRESSION: Relative haziness of the left hemithorax is likely technical, as\n above. No definite focal consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1174859, "text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: FEVER;TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with hypoxemic respiratory failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:54 A.M., \n\n HISTORY: Hypoxemic respiratory failure.\n\n IMPRESSION: AP chest compared to through 31:\n\n In the interim, the patient has been extubated, but lung volumes have\n maintained and pulmonary vasculature is no longer as engorged. The heart is\n normal in size. A small region of residual consolidation and\n small-to-moderate left pleural effusion are still present.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-01-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1174408, "text": " 1:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: FEVER;TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman s/p intubation\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post endotracheal tube placement.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: Endotracheal tube tip lies at the level of the\n clavicles approximately 4.1 cm above the carina. Feeding tube courses into\n the expected location of the stomach. Again seen are widespread confluent\n alveolar opacities with relative sparing of the lung apices, unchanged\n compared to the prior study.\n\n" }, { "category": "Radiology", "chartdate": "2178-01-18 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1174661, "text": " 7:22 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please evaluate for intracranial pathology\n Admitting Diagnosis: FEVER;TACHYCARDIA\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with fever, headache and ARDS of unknown etiology\n REASON FOR THIS EXAMINATION:\n Please evaluate for intracranial pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 28-year-old female with fevers, headache, and ARDS.\n\n COMPARISON: CT performed .\n\n TECHNIQUE: Multiplanar, multisequence images were acquired of the brain with\n and without intravenous contrast.\n\n FINDINGS: In the left occipital lobe, there is a cortically based focus of\n diffusion restriction with corresponding T2 signal hyperintensity. Smaller\n punctate foci of T2 hyperintensity are seen within the high left parietal\n cortex (9; 20). The white matter is normal in appearance. matter/white\n matter differentiation is preserved. The ventricles and sulci are normal in\n size and configuration. There are no foci of abnormal enhancement. Note is\n made of a right frontal lobe venous angioma (12;14). The contents of the\n posterior fossa, brainstem, and cervical cord are normal in appearance. The\n patient is intubated. The visualized soft tissues and orbits are normal in\n appearance. Mucosal thickening of the ethmoid air cells and fluid within the\n bilateral mastoids consistent with intubated state.\n\n IMPRESSION: Focus of cortically based diffusion restriction in the left\n occipital lobe, consistent with embolic infarction, bland or septic.\n\n Findings discussed with Dr. , of the MICU team at 11AM.\n\n" }, { "category": "Radiology", "chartdate": "2178-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1174237, "text": " 9:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulmonary process\n Admitting Diagnosis: FEVER;TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with suspected Viral illness now desatting to 88% on 4L.\n REASON FOR THIS EXAMINATION:\n r/o pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Suspected viral illness, now with desaturation on 4 L.\n\n PORTABLE AP CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS: Compared to study from one day prior there is now a profound change\n in the appearance of the chest with possible multifocal nodular opacities.\n There is also marked increase diffuse haziness overlying bilateral lungs,\n which may be due in part to breast shadows, but layering effusions or edema\n may be present. The heart appears grossly stable in size. There is no\n pneumothorax. There is an old deformity of the right first and second ribs.\n\n IMPRESSION:\n\n Possible multifocal opacities, which could be infectious. Possible edema\n accounting for the increased haze overlying bilateral lungs, but appears\n somewhat atypical. If possible a lateral CXR could be performed to better\n evaluate. If not, then a chest CT could be performed.\n\n Findings were discussed via telephone with Dr. at approximately\n 11:45 a.m. .\n\n" }, { "category": "Radiology", "chartdate": "2178-01-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1174586, "text": " 2:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: change from prior\n Admitting Diagnosis: FEVER;TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n change from prior\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 03:20 A.M. ON \n\n HISTORY: ARDS.\n\n IMPRESSION: AP chest compared through :\n\n Diffuse infiltrative abnormality which progressed so dramatically between\n and continues to clear. Bibasilar opacification is\n probably largely atelectasis and a moderate right pleural effusion, which\n increased in size yesterday is stable. The heart is normal size. There are\n no findings to suggest any substantial component of cardiac related pulmonary\n edema.\n\n Nasogastric tube passes below the diaphragm and out of view. ET tube tip\n above the upper margin of the clavicles is no less than 5.5 cm above the\n carina. If the tube remains in it should be advanced 2 cm to give more\n reliable seating.\n\n Findings were discussed by telephone with Dr. at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-01-17 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1174543, "text": " 1:56 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: intrathoracic or abdominal process that could explain fever,\n Admitting Diagnosis: FEVER;TACHYCARDIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with fever, HA, now intubated\n REASON FOR THIS EXAMINATION:\n intrathoracic or abdominal process that could explain fever, sepsis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO\n\n INDICATION: 20-year-old female with fever and sepsis, intubated. Recent\n travel to . Query cause.\n\n COMPARISON: No prior CT imaging available for comparison.\n\n TECHNIQUE: MDCT axially acquired images from the lung apices to the pubic\n symphysis displayed with 5-mm slice thickness with oral and IV contrast.\n Coronal and sagittal 3D reformats have been provided.\n\n FINDINGS:\n\n CT THORAX:\n Patient is intubated with the endotracheal tube lying approximately 1.5 cm\n above the carina. Nasogastric tube is also noted in situ.\n No pathologically enlarged mediastinal, hilar, internal mammary or axillary\n adenopathy.\n There is diffuse consolidation with associated airbronchograms noted within\n the posterior segements of the upper lobes bilaterally.\n There is patchy ill-defined ground-glass change with relative sparing of the\n periphery noted within the lower lobes bilaterally.Findings are worrisome for\n an ARDS type pattern.\n There are bilateral pleural effusions and compressive atelectasis of the lower\n lobes bilaterally.\n No pericardial effusion is noted.\n\n\n CT ABDOMEN:\n No focal liver lesion.\n No intra- or extra-hepatic biliary dilatation. Portal vein is patent.\n Gallbladder is unremarkable.\n Spleen measures 10 cm.\n Both adrenal glands, pancreas and kidneys are unremarkable.\n There are no retroperitoneal masses or adenopathy.\n No abnormality identified in relation to small or large bowel loops.\n No intra-abdominal collection identified.\n\n\n CT PELVIS:\n (Over)\n\n 1:56 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: intrathoracic or abdominal process that could explain fever,\n Admitting Diagnosis: FEVER;TACHYCARDIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Small trace of free fluid is noted within the pelvis, likely physiological.\n Intrauterine device is noted within the uterus.\n No adnexal mass.\n Urinary catheter noted within the bladder.\n Rectum and sigmoid colon are unremarkable.\n\n\n CT OSSEOUS SKELETON:\n No osseous destructive lesion.\n\n\n IMPRESSION:\n 1. Diffuse bilateral upper lobe pneumonia - differential includes viral or\n atypical pneumonia. Extensive ground-glass infiltrates bilaterally concerning\n for ARDS.\n 2. Bibasal pleural effusions and compressive atelectasis.\n 3. No intra-abdominal abscess evident.\n 4. IUD seen in the uterus\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2178-01-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1174541, "text": " 1:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: infection, bleed, other acute process\n Admitting Diagnosis: FEVER;TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with fever, HA, now intubated\n REASON FOR THIS EXAMINATION:\n infection, bleed, other acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb SAT 3:16 PM\n PFI:\n\n No acute hemorrhage or other acute abnormalities. MRI would be more sensitive\n to detect infectious intracranial complications.\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE UNENHANCED CT HEAD\n\n HISTORY: Fever, headaches, intubated.\n\n COMPARISON: None.\n\n FINDINGS:\n\n There is no acute intracranial hemorrhage or acute transcortical infarction.\n There is no midline shift or mass effect. There is no hydrocephalus or acute\n ischemia. Evaluation of the posterior fossa is limited by motion artifact.\n There is fluid in the nasopharyngeal lumen probably related to intubation.\n Otherwise, the sinuses are clear, as are the mastoid air cells.\n\n IMPRESSION:\n\n No acute hemorrhage or other acute abnormalities. MRI would be more sensitive\n to detect infectious intracranial complications.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-01-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1174542, "text": ", R. MED MICU 1:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: infection, bleed, other acute process\n Admitting Diagnosis: FEVER;TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with fever, HA, now intubated\n REASON FOR THIS EXAMINATION:\n infection, bleed, other acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n No acute hemorrhage or other acute abnormalities. MRI would be more sensitive\n to detect infectious intracranial complications.\n\n\n" }, { "category": "Echo", "chartdate": "2178-01-21 00:00:00.000", "description": "Report", "row_id": 90832, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Endocarditis. Source of embolism. Valvular heart disease.\nHeight: (in) 64\nWeight (lb): 163\nBSA (m2): 1.79 m2\nBP (mm Hg): 130/71\nHR (bpm): 107\nStatus: Inpatient\nDate/Time: at 13:34\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe aortic arch was not visualized well due to patient gagging and\nself-extubation.\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD or PFO by\n2D, color Doppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. No atheroma in descending\naorta.\n\nAORTIC VALVE: Bicuspid aortic valve. Moderate-sized vegetation on aortic\nvalve. Severe (4+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. 0.1 mg of IV glycopyrrolate was given as\nan antisialogogue prior to TEE probe insertion. No TEE related complications.\nContrast study was performed with 3 iv injections of 8 ccs of agitated normal\nsaline, at rest, with cough and post-Valsalva maneuver. The patient appears to\nbe in sinus rhythm. Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nNo atrial septal defect or patent foramen ovale is seen by 2D, color Doppler\nor saline contrast with maneuvers. Overall left ventricular systolic function\nis normal (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve is functionally bicuspid (fusion of the right and\nleft coronary leaflets). There is a echodensity seen at the tips of the aortic\nvalve leaflets that measures 0.7 x 0.8 cm and could reporesent a vegetation or\npartial flail leaflet. This is best seen in clips 77, 78 and 81 (also 10,13,\n28, 31, 37-47). Severe (4+) aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. No mass or\nvegetation is seen on the mitral valve. Trivial mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nIMPRESSION: Probable moderate sized vegetation on bicuspid aortic valve.\nSevere (4+) aortic regurgitation. No intracardiac shunt identified. Normal\nglobal left ventricular systolic function.\n\nDr. was notified by telephone on at 1:30pm.\n\n\n" }, { "category": "Echo", "chartdate": "2178-01-19 00:00:00.000", "description": "Report", "row_id": 90833, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 64\nWeight (lb): 140\nBSA (m2): 1.68 m2\nBP (mm Hg): 123/70\nHR (bpm): 116\nStatus: Inpatient\nDate/Time: at 15:48\nTest: Portable TTE (Congenital, complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD or PFO by 2D, color Doppler or saline\ncontrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal descending aorta diameter. No 2D or Doppler evidence of\ndistal arch coarctation.\n\nAORTIC VALVE: Bicuspid aortic valve. No AS. Significant AR, but cannot be\nquantified.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\nSuboptimal image quality - poor apical views. The patient appears to be in\nsinus rhythm. Echocardiographic results were reviewed by telephone with the\nhouseofficer caring for the patient.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. No atrial septal\ndefect or patent foramen ovale is seen by 2D, color Doppler or saline contrast\nwith maneuvers (Late bubbles are seen in the left heart c/w transpulmonic\npassage). Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). The estimated cardiac index is\nnormal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion\nare normal. The aortic valve appears bicuspid with eccentric closure and fused\nright and left raphe. No discrette vegetations are seen. There is no aortic\nvalve stenosis. Significant aortic regurgitation is present ?mild, but cannot\nbe quantified. The mitral valve appears structurally normal with trivial\nmitral regurgitation. There is no mitral valve prolapse. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Bicuspid aortic valve with aortic regurgitation. Normal\nbiventricular cavity sizes with preserved global and regional biventricular\nsystolic function.\nIf clinically indicated, a TEE is suggested to better define the aortic valve\nmorphology and severity of aortic regurgitation.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "Echo", "chartdate": "2178-01-16 00:00:00.000", "description": "Report", "row_id": 90834, "text": "PATIENT/TEST INFORMATION:\nIndication: R/O Endocarditis. Left ventricular function. Right ventricular function.\nHeight: (in) 64\nWeight (lb): 150\nBSA (m2): 1.73 m2\nBP (mm Hg): 113/70\nHR (bpm): 122\nStatus: Inpatient\nDate/Time: at 11:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No valvular AS. The increased transaortic velocity is related to\nhigh cardiac output. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. No mass or vegetation on\nmitral valve. No MS. MR present but cannot be quantified.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No TS. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Right ventricular chamber size and free wall motion are normal.\nThe diameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. No masses or vegetations are seen on the aortic valve. There is no\nvalvular aortic stenosis. The increased transaortic velocity is likely related\nto high cardiac output. No aortic regurgitation is seen. The mitral valve\nleaflets are structurally normal. There is no mitral valve prolapse. No mass\nor vegetation is seen on the mitral valve. Mitral regurgitation is present but\ndifficult to quantify due to tachycardia (probably trace or mild). Moderate\n[2+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: No valve vegetations seen. If indicated, a TEE would better to\nexclude a small valve vegetation and/or abcess.\n\n\n" }, { "category": "ECG", "chartdate": "2178-01-23 00:00:00.000", "description": "Report", "row_id": 230843, "text": "Sinus rhythm. Findings are within normal limits. Compared to the previous\ntracing of there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2178-01-22 00:00:00.000", "description": "Report", "row_id": 230844, "text": "Sinus rhythm. Early R wave transition. Non-specific ST segment changes\ninferiorly. Compared to the previous tracing of the ventricular rate is\nslower.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2178-01-21 00:00:00.000", "description": "Report", "row_id": 230845, "text": "Sinus tachycardia. Left atrial abnormality. Non-specific ST segment changes\ninferiorly. Compared to the previous tracing of earlier the same day the rate\nhas increased and non-specific ST segment abnormalities are now present in the\ninferior leads.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2178-01-21 00:00:00.000", "description": "Report", "row_id": 230846, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of the\nrate has slowed and diffuse T wave changes are no longer appreciated. Baseline\nartifact is not present on the current tracing.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2178-01-15 00:00:00.000", "description": "Report", "row_id": 231063, "text": "Baseline artifact. Sinus tachycardia. Diffuse T wave changes which are\nnon-specific. Compared to the previous tracing of there is no\nsignificant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2178-01-15 00:00:00.000", "description": "Report", "row_id": 231064, "text": "Sinus tachycardia. ST segment flattening inferiorly Compared to the previous\ntracing of the rate is slower. Delayed R wave progression is no longer\nseen and there is now evidence of non-specific ST segment changes inferiorly.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2178-01-14 00:00:00.000", "description": "Report", "row_id": 231065, "text": "Sinus tachycardia. Left atrial abnormality. Early R wave transition. No\nprevious tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2155-08-02 00:00:00.000", "description": "Report", "row_id": 1613542, "text": "MICU PROGRESS NOTE\n0300-0700\nCODE STATUS: DNR/DNI\n82yo female who was experience SOB x 2hrs at home, pt thought she was having an anxiety attack; and took Xanax with no effect. Pt then called 911. Pt HR 130-160's upon arrival to ED, found to be in Afib. SBP 150/120; denied CP. Pt recvd 4mg Morphine/80mng lasix/Nitropaste/ASA 325mg in ED. Pt weaned off CPAP, and placed on 4L before arrival to unit. CXR showed CHF, rt LL pneumonia recvd Levoflacin in ED\n\n\nNEURO: Pt alert/oriented x3, follows commands; mae. pupils =/reactive 3mm.\n\nCARDIO: HR 100-120's, Aflutter; HR 120's pt medicated with 40mg Verapamil po. SBP 120's. Repeat EKG done at 0400; no changes. T96.1 Positive pedal pulses bilat, no edema noted.\n\nRESP: LSC, dim bilat. no SOB noted. Pt currently on 4LNC, O2Sats 95-97%.\n\nGI/GU: hypoactive bowel sounds, abdomen large distended; pts baseline. Pt c/o some nausea upon arrival to unit; but quickly passed\nFoley cath patent, draining yellow urine.\n\nPLAN\nCont to monitor labs, cycle Cardiac enzymes\ncont to monitor VS, HR\n\n" }, { "category": "Nursing/other", "chartdate": "2155-08-02 00:00:00.000", "description": "Report", "row_id": 1613543, "text": "Nursing Progress/Transfer note 0700-1800\nThis 82yo woman was admitted from senior living facility via ED with C/O increasing SOB over several hrs assoc with palpitations, no CP. She took kXanax for ? panic attack without relief, then called 911. Enroute she rec'd NTGPaste and Lasix 80mg IV. In ED HR in RAF 130-160's, and CXR showed CHF and ? PNA in RLL. Afebrile, WBC 19.8. Pt briefly on BiPAP and NTG qtt. Also diltiazem 5mg IV X 3. Pt admitted to MICU-6 @ 0300.\n\nReview of systems:\n\nNeuro: Pt X 3, irritableafter not sleeping overnight. Denies pain and nausea. Pt reports no difficulty amb, although reports bruising toes after falling @ home. Pt rec'd Xanax PRN for anxiety, last dose 1645.\n\nResp: O2 sat 95-97% on 4l NC with RR 17-28 and regular. Lung snds clear in upper lobes diminished in LL with faint crackles. Pt expectorated small amt brown sputum X 1,\n\nCV: HR 117->88Afib/flutter without VEA. BP 122/79-96/54. AM Lopressor held D/T SBP<100. Cardiac ECHO done.\n\nGI: Abd soft with + BS. Pt reports chronic constipation, and rec'd colace and senna in am. Fair appetite on heart healthy diet.\n\nGU: Urine yellow/clear, drianing via foley @ 15-100ml/hr. Last dose Lasix @ 0400. LOS fluid balance -500ml.\n\nID: Afebrile. No further antibiotic tx @ this time.\n\nSocial: Pt spoke with dgtr/proxy, . Pt has declared self DNR/DNI.\n\nPlan: Transfer to CC7. Cont to adjust cardiac meds and resp tx. Cont emotional support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2155-08-05 00:00:00.000", "description": "Report", "row_id": 1613544, "text": "Nursing 0001-0700\n\nSee admit note for PMH. Pt is a FULL CODE. triggered on CC7 for increased HR, SOBand HTN.\n\nNeuro: Pt arrived to the floor Alert and oriented X2. After being on Bi-Pap pt started to become A&Ox3 and continues to be A&)x3. Pt able to follow all commands and is able to move all extremeties. Pt has had no c/o pain or discomfort. PERLA.\n\nCV: afebrile 98.7 PO, arrived to the floor with a HR of 133, in A-fib/flutter. Pt was given 10mg of IV lopressor and 50mg of PO lopressor. Pt continues in Afibb/Flutter however HR down to 80-90's. Pt arrived to the floor with NBP 153/67 -> currently 101-130/50-60 (70\"s). +PP skin is warm and dry. No chest pain or chest discomfort noted or stated by the pt. ECG done before transfer from CC7 and upon arrival to the MICU.\n\nRespiratory: Pt arrived to the floor on Bipap. now on 4L NC. Last ABG on 4L = 7.37/56/72. Lung sound upon arriving to the MICU were crackles way up bilat. pt received 80mg of IV lasix with poor results, foley drained only 100cc to lasix. Pt lung sounds currently are ins/exp wheezes, pt receiving nebulizer treatments by RT.\n\nGI: abdomen is soft nontender with bowel sounds present in all quadrents. No BM since arriving to the MICU, however + flatus.\n\nGU: Foley draining clear yellow urine 40-45cc/hr. CREAT 1.1 and BUN 30.\n\nSkin is intact, daughter spoke to MD and given update several times through out the night.\n\nplan: continue with diuresis. ? SW consult in regards to code status, ABG to be obtained at 0800, provide emotional support to both pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2155-08-05 00:00:00.000", "description": "Report", "row_id": 1613545, "text": "Resp Care\n\nPt transferred from CC 7 after desaturating and change in MS. BS on adm to MICU were I+E wheezes and crackles. Pt placed on NIV 10/+5, 50% and given 80 lasix with good result. Currently she is on 4 L NC and 50% face tent added because Po2 was in 70's on 4 l alone, which was lower than baseline Po2. Current Spo2 is 97%. Pt still has some wheezes and crackles minimally improved with Xopenex and Atrovent. need to go back on NIV @ some point.\n" }, { "category": "Nursing/other", "chartdate": "2155-08-05 00:00:00.000", "description": "Report", "row_id": 1613546, "text": "Nurse Progress Note 0700-1900\n\nEvents: Initially apprhensive about medications extensive med review w/ pt and team- heart failure/BP meds staggered w/ diuresis w/ good effect. SOB/dyspnes/wheezing improving over day. Meeting w/ social work and team about medication care/code status-remains full code @ this time. See carevue for details.\n\nNeuro/Pain: MS /angry in AM, expressed frustration over hospital and medications. Emotional support given, pt meeting w/ home MD , reviewing med dosing and POC. Alert, oriented w/ frustration over orientation questioning- c/o HA -requesting and recieving 650mg Acetaminophen w/ complete relief. Dosing intermittently-c/o \"I haven't been getting my anxiety medications-denies anxiey @ this time but wished to recieve @ night for sleep. PERL. Performing most ADL's w/ assistance.\n\nResp: AM tachypnic- vague answering of resp distress, RR 30-low 40's, recieved on NC 4L, face mask 70% sat 90-96% LS mild insp and large exp wheeze throughout- great improvment w/ nebs over day. O2 titrated to 4-6 L NC w/ sat 91-95%. PT has dry nonproductive cough. LS crackles @ bases L>R w/ mild improvement throughout day. Appers more comfortable resting in bed, denies SOB/trouble breathing.\n\nCV: HR 70-low 100's AFib/Aflutter-pt accepting 150mg Metoprolol in AM staggered w/ 80mg IV Lasix, and Verapamil. BP 110-156/52-87 MAP 67-104. Post IV Lasix >500cc out/2hrs. Mild pedal/ankle edema tapering up calf. Known heart failure- EF >55% w/ known MR .\n\nGI: Poor appitite, c/o \"I'll get constipated\"-no BM but commode @ bedside.\n\nGU: Clear to pale yellow urine via foley. UOP 45-220 cc/hr. Neg 1315 while in past 24hrs, neg 1843 LOS- goal neg 1-2 MD overnight for further Diuretics.\n\nFEN/ENDO: No IVF. No repete labs. Poor appitite-heart healthy Na restricted diet reviewed, daughter leaving @ bedside.\n\nSkin: Declined to roll side to side in bed, turning self and requesting to stay \"completely upright\", no breakdown in skin integrity noted.\n\nSocial: Pt daughter contacting pt via bedside phone-in to visit in afternoon. Meeting w/ MD and social work, pt and daughter to review medications - pt and family still reviewing code status. Full Code.\n\nPOC\n1. Cont monitor resp status, nebs, inhailers, wean O2 as toelrated\n2. Cont emotional support of pt and family\n3. Goal neg 1-2L, assess for further diuresis\n4. Cont all routine ICU care\n" }, { "category": "Nursing/other", "chartdate": "2155-08-06 00:00:00.000", "description": "Report", "row_id": 1613547, "text": "MICU NURSING NOTES:\n\nPLEASE REVIEW CAREVUE FOR ADM HIST, PMH & OBJECTIVE DATA.\n\nNO SIGNIGICANT EVENTS TILL TIME NOTED.\n\nNEURO: ALERT, ORIENTED X 3, COOPERATIVE WITH CARE. ALPRAZOLAM X 1 GIVEN WITH GOOD EFFCT. ABLE TO GET ON TO COMMODE WITH 1 ASSIST. DENIES PAIN. PT IS VERY CONCERNED ABOUT THE DOSES OF HER MEDS AS SHE STATES \" THEY SCREWED UP MY MEDS\". EVERY DETAIL OF HER MEDS EXPLAINED BEFORE GIVING EACH OF THEN PT'S SATISFACTION. SLEPT WELL THRU THE NIGHT.\n\nRESP: CONTINUED ON O2 4 LITS/MIN VIA NC, SATS IN MID 90'S. LS COARSE WITH DIMISHED BASES. CONT ON NEBS. AM CHEST X RAY DONE.\n\nCVS: A-FIB , NO PVC'S SEEN. HR 80'S TO 90'S. BP WNL.\n\nGI/GU: ABD SOFT, BS PRESENT, NO BM TILL TIME NOTED, CONTINUED ON COLACE. ON REGULAR CARDIAC HEALTY DIET WITH MLS OF FLUID RESTRICTION. FOLEY DRAINING MINIMAL AMBER CLEAR URINE. WAS NEGATIVE 1415 MLS BY MN.LASIX NOT GIVEN TILL TIME NOTED, WILL CONTINUE MONITORING.\n\nSKIN: INTACT.\n\nSOCIAL: DAUGHTER CALLED, UPDATED. CODE STATUS STILL TO BE CONFIRMED, PT WANTS TO BE A DNR/DNI BUT DAUGHTER WANTS HER TO BE A FULL CODE. SOCIAL WORKER FOLLOWING UP. ? CALL OUT IN AM.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2155-08-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1024995, "text": ", MED MICU 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with a.fibb w/RVR and resp distress, pulm edema\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n PFI REPORT\n Pulmonary edema almost cleared. Severe cardiomegaly persists. Rightward\n tracheal displacement suggests an enlarged left lobe of the thyroid gland,\n present since at least .\n\n\n" }, { "category": "Radiology", "chartdate": "2155-08-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1024780, "text": " 10:44 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Pulmonary edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with AFib and SOA.\n REASON FOR THIS EXAMINATION:\n Pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AFib and shortness of breath, to evaluate for pulmonary edema.\n\n FINDINGS: In comparison with the earlier study of this date, persistent\n enlargement of the cardiac silhouette with evidence of elevated pulmonary\n venous pressure that may be somewhat increased from the previous study. In\n addition, there is an area of more focal opacification at the right base with\n poor definition of a portion of the right heart border. This raises the\n possibility of developing right middle lobe pneumonia. Atelectatic changes or\n possibly even consolidation is also seen at the left base medially.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1024388, "text": " 12:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/o CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with resp distress\n REASON FOR THIS EXAMINATION:\n f/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old woman with respiratory distress. Evaluate for CHF.\n\n COMPARISON: None.\n\n SINGLE BEDSIDE AP VIEW OF THE CHEST:\n\n There is moderate pulmonary edema with more confluent right lower lobe\n opacity. . Pleural effusions if any are small. There is severe cardiomegaly.\n Aortic knob calcifications are noted.\n\n\n IMPRESSION: Moderate pulmonary edema, confluent right lower lobe opacity\n could represent developing alveolar edema or pneumonia. Severe cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1024425, "text": " 9:37 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: causes of resp distress, superimposed pna?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with pulm edema, afib, chf, copd\n REASON FOR THIS EXAMINATION:\n causes of resp distress, superimposed pna?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pulmonary edema, AFib, CHF, COPD. Question superimposed pneumonia.\n\n CHEST, SINGLE AP VIEW.\n\n Lordotic positioning.\n\n There is moderately-severe cardiomegaly, with prominence of the main pulmonary\n artery contour. No CHF, focal consolidation, or effusion is identified. There\n are some increased markings in the right cardiophrenic region similar to\n , likely reflecting the presence of some local scarring. Otherwise, no\n focal infiltrate is identified. Diffuse osteopenia is suggested.\n\n IMPRESSION:\n\n Cardiomegaly with prominence of the main pulmonary artery. Scarring right\n cardiophrenic angle. No acute superimposed process identified.\n\n" }, { "category": "Radiology", "chartdate": "2155-08-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1024622, "text": ", M. MED CC7A 1:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PNA, assess for edema.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CHF, xferred from MICU for pulmonary edema, now with new\n fevers and mild SOB.\n REASON FOR THIS EXAMINATION:\n R/O PNA, assess for edema.\n ______________________________________________________________________________\n PFI REPORT\n No appreciable change since the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-08-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1024621, "text": " 1:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PNA, assess for edema.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CHF, xferred from MICU for pulmonary edema, now with new\n fevers and mild SOB.\n REASON FOR THIS EXAMINATION:\n R/O PNA, assess for edema.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 10:36 AM\n No appreciable change since the prior study.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever and shortness of breath.\n\n Portable AP chest radiograph was compared to obtained at 10:00\n a.m.\n\n The cardiomegaly is moderate, unchanged. Bulging of the pulmonary trunk as\n well is relatively large. Right pulmonary artery is demonstrated consistent\n with pulmonary hypertension. Calcifications of the mitral annulus are again\n noted.\n\n There is mild interstitial prominence on the current study which is not\n significantly different in appearance compared to multiple prior studies. The\n right lower lung opacity is unchanged dating back to most\n likely representing area of chronic scarring. There is no appreciable pleural\n effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-08-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1024794, "text": " 2:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with a.fibb w/RVR and resp distress, pulm edema\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress and pulmonary edema, to evaluate for change.\n\n FINDINGS: In comparison with the study of , the right heart border is now\n quite well seen. Cardiomegaly with evidence of elevated pulmonary venous\n pressure persists. The opacification at the right base may merely reflect\n crowding of vessels rather than acute pneumonia. A lateral view would be most\n helpful to make this distinction.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-08-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1024994, "text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with a.fibb w/RVR and resp distress, pulm edema\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 1:43 PM\n Pulmonary edema almost cleared. Severe cardiomegaly persists. Rightward\n tracheal displacement suggests an enlarged left lobe of the thyroid gland,\n present since at least .\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:18 A.M., ON .\n\n HISTORY: A-Fib and respiratory distress. Suspect pulmonary edema.\n\n IMPRESSION: AP chest compared to and 29:\n\n Mild pulmonary edema continues to improve. Severe cardiomegaly including\n large left atrium is stable. The lungs clear of any focal abnormality. No\n pleural effusion. Mild rightward displacement and indentation of the trachea\n at the thoracic inlet, suggesting an enlarged left thyroid lobe, has been a\n constant feature since .\n\n\n" }, { "category": "Echo", "chartdate": "2155-08-02 00:00:00.000", "description": "Report", "row_id": 95388, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function\nHeight: (in) 59\nWeight (lb): 144\nBSA (m2): 1.61 m2\nBP (mm Hg): 114/62\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 10:48\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). TDI E/e' >15, suggesting PCWP>18mmHg. Transmitral Doppler and TVI c/w\nGrade II (moderate) LV diastolic dysfunction. No resting LVOT gradient. No\nVSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR. [Due to acoustic shadowing, the\nseverity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nConclusions:\nThe left atrium is dilated. The right atrium is moderately dilated. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is normal (LVEF 60%).\nTissue Doppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent\nwith Grade II (moderate) LV diastolic dysfunction (pseudonormal left\nventricular inflow Doppler spectrum). There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion. There is an anterior\nspace which most likely represents a fat pad.\n\nCompared with the findings of the prior report (images unavailable for review)\nof , the findings are similar. The left ventricle is hypertrophic\nand displays reduced diastolic compliance.\n\n\n" }, { "category": "ECG", "chartdate": "2155-08-08 00:00:00.000", "description": "Report", "row_id": 253866, "text": "Atrial fibrillation with rapid ventricular response and ventricular premature\nbeats or aberrant ventricular conduction. Left ventricular hypertrophy with\nsecondary repolarization changes. Compared to the previous tracing of \nthe rate has increased. The other findings are similar.\n\n" }, { "category": "ECG", "chartdate": "2155-08-05 00:00:00.000", "description": "Report", "row_id": 253867, "text": "Atrial fibrillation. Left ventricular hypertrophy. Non-specific ST-T wave\nchanges. Compared to tracing #2 no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2155-08-05 00:00:00.000", "description": "Report", "row_id": 253868, "text": "Atrial fibrillation. Left ventricular hypertrophy. Early transition.\nNon-specific ST-T wave changes. Compared to tracing #1 the ventricular rate is\nslower and the ST segment depression is less pronounced.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2155-08-04 00:00:00.000", "description": "Report", "row_id": 253869, "text": "Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave\nchanges. Possible left ventricular hypertrophy. Compared to the previous\ntracing of the ventricular rate is faster and the lateral ST segment\ndepression is more pronounced.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2155-08-02 00:00:00.000", "description": "Report", "row_id": 253870, "text": "Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave\nchanges. Possible left ventricular hypertrophy. Compared to the previous\ntracing of the lateral ST segment depression with T wave inversion\nis less pronunced and the ventricular rate is faster.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2119-05-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1016535, "text": " 9:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please evaluate lung fields, evidence of CHF, effusion, hear\n Admitting Diagnosis: NSTEM;? ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CAD s/p CABG, BiV ICD placement, CHF, presenting to OSH\n with AMS, fevers, and positive blood cultures\n REASON FOR THIS EXAMINATION:\n Please evaluate lung fields, evidence of CHF, effusion, heart size\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW, ON \n\n HISTORY: CHF, altered mental status, and fever, positive blood cultures.\n\n REFERENCE EXAM: .\n\n FINDINGS: Again seen is a cardiac pacer with three leads in unchanged\n positions. Sternal wires and mediastinal clips are again visualized. There\n is moderate cardiomegaly with pulmonary vascular re-distribution, perihilar\n haze consistent with CHF. This is increased compared to the prior study.\n There is retrocardiac opacity that could be due to volume\n loss/infiltrate/effusion.\n\n IMPRESSION: Increased CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-05-13 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1016580, "text": " 11:03 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: ,EVAL FOR HYDRO\n Admitting Diagnosis: NSTEM;? ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with septic like picture, has suprapubic catheter and renal\n failure. also with R. hip pain\n REASON FOR THIS EXAMINATION:\n Please evaluate site under suprapubic catheter ? abscess, also concern for\n cause of renal failure, ? obstruction. Please look at right hip for any fluid\n collection as well\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old female with sepsis, suprapubic catheter and renal\n failure. Evaluate for possible abscess.\n\n No prior studies for comparison.\n\n FINDINGS: Grayscale evaluation of bilateral kidneys reveals no evidence of\n stones, or hydronephrosis. There is a simple cyst within the mid pole of the\n left kidney, measuring approximately 1.9 cm.\n\n There is a suprapubic catheter seen coursing into the bladder. Mild anechoic\n region surrounding of course of the superior catheter likely reflects a small\n amount of fluid or edema. There is no evidence for a discrete abscess.\n Initial images which demonstrate a rounded heterogeneous appearance\n approximately 1.6 cm adjacent to the region of the bladder was not\n reproducible upon re-examination, and may have reflected either a portion of\n the bladder or bowel.\n\n IMPRESSION:\n 1. No definite evidence of an abscess.\n 2. No evidence of hydronephrosis.\n\n" }, { "category": "Radiology", "chartdate": "2119-05-13 00:00:00.000", "description": "R HIP UNILAT MIN 2 VIEWS RIGHT", "row_id": 1016591, "text": " 12:15 PM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: concern for fracture, source of pain\n Admitting Diagnosis: NSTEM;? ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with R. hip pain, sepsis\n REASON FOR THIS EXAMINATION:\n concern for fracture, source of pain\n ______________________________________________________________________________\n FINAL REPORT\n PELVIS AND RIGHT HIP ON \n\n HISTORY: Right hip pain. Sepsis.\n\n FINDINGS: No old films available for comparison. The patient is status post\n left total hip replacement with the prosthesis in good location. There are\n severe degenerative changes of the right hip with joint space narrowing,\n sclerosis, subchondral cysts and osteophytes. The margins of the entire\n humeral head cannot be adequately defined inferiorly and it is unclear if this\n is due to osteopenia or overlying osteophytes. Infection cannot be totally\n excluded and if this remains a clinical concern, recommend followup with MRI.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-05-13 00:00:00.000", "description": "R US EXTREMITY NONVASCULAR RIGHT", "row_id": 1016579, "text": " 11:02 AM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: Look at R. hip, ? fluid/abscess\n Admitting Diagnosis: NSTEM;? ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with R. hip pain, currently tx for endocarditis/sepsis\n REASON FOR THIS EXAMINATION:\n Look at R. hip, ? fluid/abscess\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old female right hip pain, currently treated for\n endocarditis sepsis. Evaluate for fluid or abscess.\n\n No prior studies for comparison.\n\n FINDINGS: Targeted grayscale evaluation of the right lateral hip were\n obtained. There is no evidence of abnormal fluid collection, or subcutaneous\n edema. No mass or focal lesion is identified. Suprapubic catheter partially\n visualized.\n\n IMPRESSION: Targeted views of the right hip demonstrate no evidence of\n abscess.\n\n" }, { "category": "Radiology", "chartdate": "2119-05-14 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1016670, "text": " 10:06 AM\n PORTABLE ABDOMEN Clip # \n Reason: please assess for any evidence of obstruction\n Admitting Diagnosis: NSTEM;? ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with nausea, vomiting, endocarditis\n REASON FOR THIS EXAMINATION:\n please assess for any evidence of obstruction\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Nausea and vomiting in a patient with endocarditis.\n\n Portable AP chest radiograph was reviewed with no prior studies available for\n comparison.\n\n The overall appearance of the abdomen is unremarkable with preserved bowel gas\n and contents. No dilated bowel loops were demonstrated. Note is made of a\n prior left hip replacement.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1016671, "text": " 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for any evidence of infiltrate, pulmonary \n Admitting Diagnosis: NSTEM;? ENDOCARDITIS\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM TO PRIOR REPORT.\n\n Findings were communicated to Dr. over the phone by Dr. at\n the time of dictation.\n\n\n\n 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for any evidence of infiltrate, pulmonary \n Admitting Diagnosis: NSTEM;? ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with rales over right base, endocarditis\n REASON FOR THIS EXAMINATION:\n please assess for any evidence of infiltrate, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Rales over the right base.\n\n Portable AP chest radiograph was compared to .\n\n The patient is after median sternotomy and CABG with unchanged cardiomegaly\n and appearance of the post-sternotomy wires. The pacemaker leads terminate in\n right atrium (one) and in right ventricle (two). The right central venous\n line tip is in mid SVC.\n\n There is interval progression in the bilateral perihilar opacities continuing\n toward the upper lungs consistent with pulmonary edema although infectious\n process in right upper lobes cannot be excluded. There is no right lower lobe\n consolidation worrisome for pneumonia. Retrocardiac atelectasis is unchanged.\n Note is made that left costophrenic angle was not included in the field of\n view.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1016883, "text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess placement of PICC, edema, consolidation\n Admitting Diagnosis: NSTEM;? ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman PICC in place, concern for movement of line, also CHF,\n endocarditis.\n REASON FOR THIS EXAMINATION:\n please assess placement of PICC, edema, consolidation\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP view on .\n\n COMPARISON: .\n\n HISTORY: 80-year-old woman with placement of PICC line, concern for movement\n of line, also congestive heart failure and endocarditis.\n\n FINDINGS:\n\n The PICC line was retracted only by at least 5 mm still terminating at the\n brachiocephalic/SVC junction.The Right IJ has been remloved. Moderate\n cardiomegaly is stable. The pulmonary edema has decreased significantly and\n less perihilar congestion is seen. There is no right pleural effusion. A\n small left pleural effusion has decreased in size. A stable dual leaded left-\n sided pacemaker is unchanged. Abandoned leads are also unchanged.\n\n IMPRESSION:\n 1. The right PICC line tip is still in satisfactory location.\n 2. Almost complete resolution of the pulmonary edema and pulmonary vascular\n congestion.\n 3. Stable moderate cardiomegaly. Improvement of the small left pleural\n effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2119-05-15 00:00:00.000", "description": "Report", "row_id": 80056, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Mitral regurgitation. Cardiomyopathy. S/P ICD placement.\nHeight: (in) 67\nWeight (lb): 160\nBSA (m2): 1.84 m2\nBP (mm Hg): 112/72\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 16:09\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\nA catheter or pacing wire is seen in the RA and extending into the RV. A\nmass/thrombus associated with a catheter/pacing wire in the RA or RV. A\nprominent Chiari network is present (normal variant). Normal interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Dilated LV cavity. Depressed LVEF.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in\nthe descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate-sized\nvegetation on mitral valve. No mitral valve abscess. Mild mitral annular\ncalcification. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR. No masses or vegetations on pulmonic valve, but cannot be\nfully excluded due to suboptimal image quality.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. 0.2 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No\nTEE related complications.\n\nConclusions:\nMild spontaneous echo contrast is seen in the body of the left atrium. A mass\nmeasuring 0.6cm in greatest width is adherent to the RV pacing lead is seen\nwithin the right atrium. No atrial septal defect is seen by 2D or color\nDoppler. The left ventricular cavity is dilated. LV systolic function appears\ndepressed. There are complex (>4mm) atheroma in the aortic arch and descending\nthoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No masses or vegetations are seen on the aortic\nvalve. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is a moderate-sized vegetation (09.x0.8 cm) on the atrial\nsurface of the posterior leaflet of the mitral valve. It is slightly mobile\nand irregular in its appearance, consistent with a vegetation or possibly a\ntorn chordae with mild calcification. No mitral valve abscess is seen. Mild to\nmoderate (+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. No masses or vegetations are seen on the pulmonic valve, but\ncannot be fully excluded due to suboptimal image quality. There is no\npericardial effusion.\n\nIMPRESSION: Small mobile echodensity on the posterior leaflet of the mitral\nvalve consistent with a vegetation. Mild to moderate mitral regurgitation.\nSmall mass adherent to the RV pacing lead seen with the body of the right\natrium, suggestive of a fibrin strand.\n\n\n" }, { "category": "Echo", "chartdate": "2119-05-13 00:00:00.000", "description": "Report", "row_id": 80057, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Left ventricular function. Shortness of breath.\nHeight: (in) 68\nWeight (lb): 181\nBSA (m2): 1.96 m2\nBP (mm Hg): 120/53\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 10:49\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\nsize. Moderate regional LV systolic dysfunction. TDI E/e' >15, suggesting\nPCWP>18mmHg. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal aortic arch diameter. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No masses or vegetations on aortic valve, but cannot be fully\nexcluded due to suboptimal image quality. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve mass.\nModerate mitral annular calcification. Moderate to severe (3+) MR.\nUninterpretable LV inflow pattern due to MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is top normal/borderline\ndilated. There is moderate regional left ventricular systolic dysfunction with\nhypokinesis of all distal segments. The apex is akinetic. Tissue Doppler\nimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The number of aortic valve leaflets cannot be\ndetermined. The aortic valve leaflets are mildly thickened. No masses or\nvegetations are seen on the aortic valve, but cannot be fully excluded due to\nsuboptimal image quality. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis a mass on the posterior leaflet of the mitral valve. This is echogenic and\nprobably represents mitral annular calcification, a vegetation or abscess is\nalso a possibility. Moderate to severe (3+) mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nIMPRESSION: Mass on posterior leaflet of the mitral valve which is likely\nmitral annular calcification although a vegetaation/abscess is also a\npossibility. Moderate to severe mitral regurgitation. A trans-esophageal echo\nmay help to clarify the mass on the mitral valve and establish whether\nendocarditis is present.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1016733, "text": " 8:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for resolution of pulmonary edema, evidence of\n Admitting Diagnosis: NSTEM;? ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with pulmonary edema, question of pneumonia, endocariditis\n REASON FOR THIS EXAMINATION:\n please assess for resolution of pulmonary edema, evidence of consolidation,\n other interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pulmonary edema with possible pneumonia, to assess for interval\n change.\n\n FINDINGS: In comparison with study of , there is again enlargement of the\n cardiac silhouette with evidence of pulmonary vascular congestion. No\n definite consolidative processes are seen in the upper lungs on this study.\n Various tubes remain in place.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-05-17 00:00:00.000", "description": "Report", "row_id": 1669422, "text": "CCU NPN 1900-0700\nS: \"I feel much better today\"\nO: Pls see careview & ICU update for further objective data\nCV: HR 60-80s Vpaced, occas Apaced c HR low 60s. Occas-freq PVCs, short runs NSVT, rate 100s-asymptomatic c stable BP. No ICD firing or ATP. NBPs 100-120s/40-60s--tol Po hydral & lopressor.\n\nRESP: O2 Sats WNL on RA. LS clear, dim at bases c intermittent faint crackles in bases. No cough.\n\nNEURO: A&Ox3. Pleasant. In gd spirits. States feels better today. No c/o pain.\n\nGI: Poor appetite per report from previous shift. Likes cold, iced water--left at bedside. Good POs, drinking throughout noc. 1 episode c/o nausea, no vomiting. 4mg Zofran given c pos effect. Colace, senna, lactulose & ducolax given per CCU intern. Tiny mucoid BM, guiac neg--in commode.\n\n" }, { "category": "Nursing/other", "chartdate": "2119-05-17 00:00:00.000", "description": "Report", "row_id": 1669423, "text": "CCU NPN 0700-1700\nS: \"I should try to eat something.\"\n\nO: Please see transfer note and careview for VS and additional data.\n\nCV: Pt HR 60-74 AV/V paced (AV pacing noted when HR 60, otherwise appears to be Vpaced), rare PVC noted. NBP 108-120/44-54. Pt cont on metoprolol, hydralazine and isosorbide. Bilat pedal pulses palp. AM K 3.7, repleted with 40 meQ KCL. No c/o CP. Cont on nafacillin for endocarditis.\n\nResp: Pt LS CTA to dim at bases. RR 15-23, O2 sats 98-100% on room air. Pt denies SOB, no cough noted.\n\nNeuro: Pt A&Ox3, MAE, able to turn self in bed, follows commands consistently. Pt asking appropriate questions re. POC. Pt OOB to chair with PT, see note in chart. Pt back to bed with 2 RN assist.\n\nGI/GU/ENDO: Pt abd soft, +BS x4, pt tol am pills and ate lunch with no c/o nausea. This afternoon at approx 1630 pt with c/o nausea, Po meds held and IV zofran given, awaiting effect. Pt with suprapubic catheter, per urololgy-> area to be cleansed with NS and bacitracin applied 3x a day. Pt also inc urine (has had mulitple bladder surgeries-wears depends as outpt). FS 118 this afternoon-no ss insulin coverage given.\n\nID: Afebrile. Cont on IV nafacillin for endocarditits, PO levofloxacin for UTI.\n\nSkin: Pt with BLANCHABLE INTACT SKIN on coccyx and buttocks. Reportedly former pressure ulcer site (appears with scarring at area).\n\nSocial: Pt with husband and 10 children, 31 grandchildren and 28 great grandchildren. Some family in at bedside this afternoon.\n\nAccess: Pt with single lumen PICC for abx.\n\nA/P: 80 y/o female with endocarditis and likely RV lead vegitation per notes cont on IV nafacillin, tolerating majority of pills with less c/o nausea. As discussed CCU MD's, cont to monitor pt hemodynmaics-meds as pt tol. Cont to monitor resp status, u/o, labs. Cont with IV abx, monitor skin, advance diet and activity as tol. Cont to provide emotional support to pt and family. Awaiting further POC CCU MD's, called out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2119-05-16 00:00:00.000", "description": "Report", "row_id": 1669420, "text": "npn\npt feeling \"whoozey\"\nneuro; aox3, very tired this am, back to bed and napped for about an hour, seems clearer after nap. able to make needs known\npain: denies although has continued to c/o nausea ? discomfort at level of sternum and diaphragm, feelings waxes and wanes thru shift, zofran given with little change in discomfort per pt although she seemed to be resting comfortably\n hr vpaced , seen by ep, ekg done with pacer off, , nbp 108/68 to 129/53, no issues, has been able to take all cardiac meds today.\nresp: ls clear thru out, sats 93-100% on ra, rr teens to 20's\ngi: c/o nausea thru out shift, pt reported that she ate meatloaf for dinner last night which made her feel sick overnight, zofran given late in afternoon with some improvement in c/o of discomfort, has had minimal po intake over shift but able to tolerate pills. intake encouraged.\ngu: suprapubic tube intact, site around tube reddish pink ? fungal inf. minimal incontinence noted during shift, uo approx >30cc/hr pt given 20 mg iv lasix at 1630 with little inc in output at this time.\nendo; bs 179-174 covered with ssi\nid: afebrile, cont on naficillin and levofloxacin for endocarditis\nplan; monitor nausea and tx prn, cont to monitor fluid status, inc. activity as tolerated, enc. po intake,\n" }, { "category": "Nursing/other", "chartdate": "2119-05-17 00:00:00.000", "description": "Report", "row_id": 1669421, "text": "CCU NPN 1900-0700\ncontinued:\n\nGI: Incont XL brown liq stool-Guiac neg at 0500. Albumin 3.2\n\nGU: SPT draining minimal amts CYU. Adult brief saturating-changed freq. Difficult to obtain accurate output. 20mg IV lasix given at 2230 to be neg (goal -500/day), only 100cc out. +178 at MN, Then uop dropped to 15cc then 0cc. CCU intern notified. Uop then picked up after. Cr improving 2.3 (2.5).\n\nID: Afebrile, WBC pnd. Cont on Nafcillin IV Q 4hrs & Levofloxacin for UTI (ecoli in urine at OSH) Q48hrs (Next dose due ). All cx here NTD.\n\nSKIN: Mult ecchymotic areas on arms d/t venipunctures/PIVs. Bilat lower legs c some pink/red circular areas. No c/o itchiness/soreness. Legs equally warm. Old sacral decub scar. Sm sized red area on sacrum-moisture barrier cream applied. Pt laying on side, completely off back (self positioning). SPT site red, greenish drainage-cleansed c NS, bacitracin ointment applied.\n\nACCESS: R upper arm single lumen PICC. R lower arm PIV d/t pain, redness and warmth.\n\nSOCIAL: Supportive family in last evening. No calls overnoc. Remains full code.\n\nA/P: 80 y/o F c Staph aureus bacteremia, + MR, new vegitation on MV c/w bacterial endocarditis, on abx. Occas episodes brief NSVT-stable. +results from aggressive bowel regimen. Nausea improving. Feeling better per pt. ? call out to floor.\nContinue present management, Replete lytes PRN c diuresis, Enc POs, Skin care, ? air bed d/t h/o decub if continues to have poor nutritional status , hold AM bowel meds for now given XL amt liq stool, OOB as tol, PT/OT. Support pt and fam PRN. Awaiting further plan from CCU team.\n" }, { "category": "Nursing/other", "chartdate": "2119-05-14 00:00:00.000", "description": "Report", "row_id": 1669415, "text": "CCU NPN 0700-1900\n80 Y/O FEMALE W/ 4/4 BOTTLES + FOR BACTEREMIA. ? Vegatation on MV. TTE done on -> MV mass ? unable to r/o vegatation.\n3+ MR, EF 30-35% (pt has BiV icd). MRSA ruled out via sensitivities. Currently on Naficillin 4 four hrs. Keflex d/c'd d/t allergy symptoms. Started on Levofloxacin. Vanco levels being followed w/ acute on chronic renal failure. cx's drawn @ 2100 & @ 0700, neg growth to date. Afebrile. WBC count bumped to 10 from 6 today.\nUrology consulted regarding SPT as source of infection, No signs of infection per urology. Bladder US, R hip US, Kidney US negative for infxn source on . R hip Xray neg for fracture on (per c/o pain per pt). Developed acute Nausea at 0500 on . Medicated w/ 8 mg total of zofran and .5mg ativan.\n\nNeuro: Sleepy but arousable. Oriented x3. turning S->s q 2-30hrs. Movement worsens nausea/ dry heaving.\nCV: Unable to take po Isosorbide today d/t nausea, team aware.\nBP 116/45 61. HCT 29.3 INR 3.1 (4.1)\nK+ 3.7 this am repleted w/ 40meq kcl. repeat K+ 5.0. Lasix given at 1400. EP interogated PACER today.\nResp: Xray shows increased pulm congestion. 20mg iv lasix given. O2 sat 93-94%.\nGI: Emesis x1 approx 100cc. Sleeping most of day, but dry heaves when awake. No po intake today. Request for commode at 1530.\nGU: Levoquin started for UTI. Incont of Urine dispite SPT. Inacurate I/O's. creat 2.7.\n\nSkin: Old sacral decub site, high risk for breakdown. Allevyn peeled off today, ? tape peeling at skin. Site left open to air. Maintain pressure off sacrum.\n\nA: + Allergy to Keflex presenting today with Nausea/vomitting.\n^wbc, afebrile on abx.\nP: Plan for TEE to assess vegatation vrs Mass on MV. NPO after mn.\nCont IV abx. Will need PICC for long term abx. Order placed for given neg cx's x48hrs. Reassess if pt spikes temp.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-05-15 00:00:00.000", "description": "Report", "row_id": 1669416, "text": "Nursing Progress Note\nTransfered from OSH for work-up of bacterial endocarditis ( MRSA ) with vegetations vs mass on posterior leaflet of MV ( 3+ ) MR. HX of 2V CABG and BIV ICD. S/P CVA on coumadin. EF of 25%\n\nNPO for TEE today.\nPossible PIC placement today\n\nCV HR 60-100's paced. SBP 110-130's/40-60's...Denies chest pain or SOB but reports intermittent nausea with movement ( turning side to side ) in bed. Deferring meds for now.\n\nResp on room air with 02 sat 97-99% Lung sounds diminished at the bases.\n\nGI/GU Urine output via SPT with incont via diaper.\n\nID Nafcillin q4 hours\n\nAM Labs pndg\n\nTurned q3 hours\n" }, { "category": "Nursing/other", "chartdate": "2119-05-15 00:00:00.000", "description": "Report", "row_id": 1669417, "text": "CCU NPN 0700-1900\nS: \"I'm at , right? Will I need more procedures?\"\n\nO: Please see careview for VS and additional data.\n\nEvents/Procedure: Pt had TEE this afternoon. Consent obtained by Dr. . Timeout done-right pt, site and procedure confirmed. Please see careview for VS throughout procedure. Pt rec'd a total of 2.5 mg versed and 0.2 mg glycopyrrolate as per Dr. . Pt tol procedure. Pt with PAR acore of 10 s/p procedure.\n\nCV: Pt had TEE as above for mitral valve vegitation/endocarditis, please see report for results. HR 60's-70's V-paced, HR occ noted for bursts ST 110's-120's-> resolved spontaneously and with coughing, CCU Team aware. NBP 105-137/40-58. Pt unable to tolerate any medications this am d/t nausea. Pt eventually rec'd isosorbide, metoprolol, IV hydralazine and aspirin. Bilat pedal pulses palp. No c/o CP. Am K 3.0, pt repleted with a total of 80 MeQ KCL-> afternoon lytes sent, results pending.\n\nResp: Pt LS clear to diminshed/faint crackles at RLL. RR 15-22, O2 sats 96-98% on room air. Pt with occ non-productive cough noted. Pt denies SOB.\n\nNeuro: Pt A&Ox3, MAE, bilat grasp appears equal, follows commands consistently, asking some appropriate questions re. POC. Pt with c/o mild HA early this afternoon-resolved with 650 mg tylenol, nausea relief and a col cloth. Pt able to assist with turning, pt turned as able as nausea increased with turning. Importance of turning verbalized to pt as pt reportedly has hx (scars noted on coccyx) of former healed pressure ulcer.\n\nGI: Pt with c/o nausea this am into this afternoon-> 4mg IVP zofran given x2 with minimal to no effect in nausea, 6.25 mg IV phenergan given with effect. Pt NPO today for TEE, tolerated cups of water with pills. Pt to have dinner this eve. No stool this shift. Abd soft, +BS x4.\n\nGU: Pt with suprapubic tube-please see careview for u/o. Pt also with incontinence-> reportedly hx of multiple bladder surgeries, on detrol , pt cont inc. Pt wears poise pads as outpt. Lasix 20 mg IV given x1 this afternoon-appears to have effect, difficult to assess as pt inc of large amounts u/o (saturating pink pad and/or diaper). Toileting offered, pt verbalized inability to control u/o.\n\nEndo: Pt FS 114-137, no ss insulin coverage given.\n\nID: Pt cont on nafacillin for bacteremia/endocarditis, levofloxacin for pan-sensitive E.Coli.\n\nAccess: Pt had PICC placed this am. TLC dc'd this eve and tip sent for cx.\n\nSocial: Pt husband and dtr in at bedside this eve. Spoke with RN and MD re. pt condition and POC.\n\nSkin: Pt with pink-red blanchable area on coccyx. Reportedly former pressure ulcer site (appears with scarring at area).\n\nA/P: 80 y/o female with endocardiditis/MV vegitation cont w/ c/o nausea-resolved with phenergan, tolerated TEE and PICC placement. As discussed with CCU MD's, cont to monitor pt hemodynamics-titrate meds as pt tol. F/u with lytes, monitor u/o, cx results, abx. Cont to provide emotional support to pt and family, awaiting further POC per CCU Team.\n" }, { "category": "Nursing/other", "chartdate": "2119-05-16 00:00:00.000", "description": "Report", "row_id": 1669418, "text": "CCU NPN 1900-0700\nS: \" I feel like I'm going to throw up \"\nO: pt. contin. to c/o nausea/dry heaves throughout eve, increasing after having small amt. of dinner at 1900. phenergan x1 - no effect. zofran x1 - no effect. exam - abd soft, NT, pos. BS. pt. states she is not passing gas. no documentation of BM since admit and pt. does not remember. team examined. given reglan 5mg x2 (2200/2300) and pt. stated she was feeling better ~ MN/0100.\nshe was able to take po antibiotic and tylenol ~ 0200 but c/o low grade nausea again at 0300. given IV phenergan with partial relief.\ntaking sips of water left at bedside. burping/hiccups\nchart review showing KUB was unremarkable/no dilated bowel.\nteam to discuss on rounds in AM- ? need for CT.\n\nID: TM 99po. levoflox first dose at 0200 - for ecoli UTI.\nnafcillin q4hr treating bacterial endocarditits.\n\nCV: HR 67-88 Vpaced. no VEA. rare episode of self limiting SVT 100-120. asymptomatic.\nBP 106/94-139/73. hydralazine IV x1. unable to take any po CV meds. team aware.\n\nResp: LS clear RA sats 94-98%. denies SOB\nGU: suprapubic catheter draining clear yellow urine. site is D/clean.\nlasix 20mg in eve. approx 700cc u/o responce. inconinent x1 in eve, using diaper tucked underneath while in bed....has not had any more incontinence tonight.\n\nGI: as above..\nskin: coccyx is pink, + blanching. barrier cream applied. pt. turning side to side with assist.\nscatt. dried small scabs on left calf...intact. heels intact. barrier cream applied.\n\nPICC dressing taken down and changed. site is pink, soft. slow ooze noted from puncture site. stable.\n\nneuro: pt. A/O x3. appearing mildly anxious d/t nausea and not feeling well. not sleeping. feeling figity. tylenol given. team declining to give anything stronger tonight. pt. calling to change position in bed q1hour , then dozed for ~ 2 hours.\nup in chair at 0300. 2 assist.\ndenies pain- \" I can't get comfortable \"\n\nA 80 yo female with with new MV vegetation and (+) BC MSSA. s/p PICC . contin. with ongoing intermittant nausea. unable to take po meds.\nP: monitor HR/BP . contin.q4hr IVAB for endocarditis and q48 po levoflox for UTI.\n? start reglan RTC- check with team on rounds in AM. give CV meds as able.\nmonitor renal status - cr 2.7. follow lytes, HCT.\nemotional support for pt. and family. tylenol for comfort.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-05-16 00:00:00.000", "description": "Report", "row_id": 1669419, "text": "npn\nadd: 1800 pt incontinent of urine and scant amt of stool , feeling nauseous again, phenergan iv given.\ngi: bisocdayl and lactulaose added to bowel regime, min results\n" }, { "category": "Nursing/other", "chartdate": "2119-05-13 00:00:00.000", "description": "Report", "row_id": 1669411, "text": "Nursing Admit Note\n This is an 80 yr old female who was admitted to an OSH with CP,SOB, fever,fatigue, nausea and hypotention on . Admit work revealed a TRPN of 2.7 and CRI of 2.4\nan echo on showed vegetations on her MV with severe MR. () grew MRSA and she was treated with vanco and oxacillin. Urine cluture was positive for ecoli. She became hypotensive and was started on dobutamine and transfered to on under the cardiology service.\n\n PMHX\nCABG ( 2v in )\nCHF ( EF 25%)\nBIV ICD in /06\nNIDDM\nHTN\nTIA on coumadin\nCRI\nSPT due to frequent UTI's\nV paced\nRight TKR\nLeft THR\n\nAllergies\nmetformain, pentazocine, propoxyphene, sulfa, tramadol, MS04\n\nEcho with multiple small masses on post MV c/w vegetations with mod TR\n\nShe was transfered to the CCU at 2100 with a right IJ triple lumen and dobutamine at 5 mcgs/kg infusing.\n\nCV HR 70-80's vpaced. SBP 100-120's/40-50's. Denies chest pain. CVP 8-11\n\nResp On room air with 02 sat 98-99% Lungs clear .. decreased at the bases.\n\nGI Abd distended but soft. Last BM on per patient.\n\nGU Admit CRI 3.2.. Urine output via spt 80-120 cc with frequent incont.. patient using large peri-pads .. changing q3 hours due to saturation. Urine foul smelling. Ecoli inher urine. on Keflex\n\nID Afebrile. wbc 5.6. Urine and sent. On contact precautions.\n\nHeme Hct 27 ..crossmatch difficult per bank INR 3.7\n\nNeuro alert and oriented .. Noted to have difficulty word finding. Poor medical historian. Affect somewhat flat.\n\nWt 80 KG\n\nPer conversation with husband ..patient needs assist with ADL's..assist with OOB... spends the day in her wheelchair. Ambulates with walker/cane. Has history of falls.\n\nConsider TTE to evaluate MV/MR\n \n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-05-13 00:00:00.000", "description": "Report", "row_id": 1669412, "text": "Pt c/o sore throat, treated w/ tylenol po w/ little effect.\nSkin: sacrum red at site of OLD sacral decub. Alevyn dressing applied.\n\nA: Afebrile on ABX, BP and VSS. Tolerating Isordil for afterload reduction. U/O adequate. Creat trending down.\nP: Vanco level in am. IV abx. Assess cardio pulm status.\nfollow temp\n" }, { "category": "Nursing/other", "chartdate": "2119-05-13 00:00:00.000", "description": "Report", "row_id": 1669413, "text": "CCU NPN 0700-1900\n\n\nCV: HR 70 Vpaced. Started on Isordil for after load reduction given reported severe MR. BP 121/46/63. Hct 27.0 and stable. Repeat INR 3.0.\nEcho done today to assess EF, MR, ? infected pace maker lead, given + cx.\n\nResp: LS clear, O2 sat 97% RA. OOB -> chair this afternoon.\n\nGI: tolerating meals, no BM. + flatulence.\nGU: R hip pain \"tolerable\" per pt. Supra pubic tube changed today by urology. Area cleansed & purulent greenish tinged drainage from SPT assessed by Urology.\nUS of Kidneys/bladder/SPT site, and R hip done today.\n\nID: afebrile started on IV naficillin, Vanco level 21.2. On PO Keflex.\n\nCont...\n" }, { "category": "Nursing/other", "chartdate": "2119-05-14 00:00:00.000", "description": "Report", "row_id": 1669414, "text": "Nursing Progress Note\n1900-0700\nUnremarkable night until 0500 when patient called out for a nurse due to sudden wretching and nausea. Hr 110 paced .. SBP 160-170/70's. Patient spitting up thick plugs of phlegm with nickel size clots. Given 8 mg zofran without affect. Dr aware. Given .5 mg of ativan ck's sent with am labs.\n\nCv hr remains in the 110's..paced ..SBP 120-170's/60-70's..INR 3.1 HCT 27.\n\nResp Room air sat 98-99% Lungs diminished at the bases RR 18-32\n\nGI asleep after zofran/ativan. No stool\n\nGU CRI 2.7 Urine output per flowsheet in addition to incont ..diaper changed several times during the night\n\nID WBC up to 10 Nafcillin q4 ..Keflex continues\n\nTurned q3 hours\n\nPacer to be interrogated today.\nReassess callout status\n" }, { "category": "ECG", "chartdate": "2119-05-18 00:00:00.000", "description": "Report", "row_id": 201585, "text": "Ventricular paced rhythm with one fusion beat. Compared to tracing #2\nthe rhythm is completely paced except for one fusion beat.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2119-05-16 00:00:00.000", "description": "Report", "row_id": 201586, "text": "Sinus rhythm with first degree A-V block. Demand ventricular pacing. Left\nbundle-branch block. Possible left ventricular hypertrophy with ST-T wave\nchanges. Compared to tracing #1 sinus rhythm and first degree A-V block\nare now present. Demand ventricular pacing is present as is left bundle-branch\nblock.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2119-05-16 00:00:00.000", "description": "Report", "row_id": 201587, "text": "Ventricular paced rhythm with a ventricular premature beat. Compared to the\nprevious tracing of the ventricular premature beat is new. Ventricular\nrate is slower.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2119-05-14 00:00:00.000", "description": "Report", "row_id": 201588, "text": "Atrial sensed and ventricular paced rhythm. All ventricular complexes\nare paced. Compared to the previous tracing of rate has increased\nand ventricular premature beat is no longer present. Current rate of 85\nis possibly because of the application of a magnet over the pacemaker.\n\n" }, { "category": "ECG", "chartdate": "2119-05-13 00:00:00.000", "description": "Report", "row_id": 201589, "text": "Ventricularly paced rhythm at 70 beats per minute. No diagnostic change from\ntracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2119-05-12 00:00:00.000", "description": "Report", "row_id": 201590, "text": "Ventricularly paced rhythm with atrial sensing at a rate of 77 beats per\nminute. Compared to the previous tracing of no diagnostic interval\nchange.\nTRACING #1\n\n" } ]

[ { "category": "Physician ", "chartdate": "2206-01-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 364896, "text": "Chief Complaint: Shortness of breath, increased sputum production\n HPI:\n 62 y/o F with PMHx of CAD s/p MI, COPD on 2L home O2 and IgA deficiency\n who presents with progressive SOB over last 4-5 days with cough and\n increased sputum production. Pt recently finished prednisone taper on\n . Pt with multiple sick contacts recently, including \"strep\n throat.\" She denied CP, abd pain, nausea, vomiting, diarrhea, fever and\n chills.\n .\n In the ED, initial vs were: T 98.1 P 110 BP 121/79 R 38 sats 100% on\n NRB. Patient was given Solumedrol 125mg IV, Levofloxacin 750mg, and\n stacked nebs. BP was noted to trend down to 90/50s and pt received NS\n 500cc bolus, repeat bp 104/62. Pt was mentating okay on CPAP.\n .\n On arrival to the ICU pt was breathing more comfortably on CPAP. Pt\n felt symptomatically improved although still appeared tachypneic.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66%\n (61% and 40% predicted respectively); intubated several times in\n the past. on 2L home O2.\n - IgA deficiency, was on IV gamma globulin with Dr. .\n - CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in\n (chest pain with left arm discomfort). Cath in with\n PTCA/stent to LCx. Cath in with stent placement to RCA\n and LCx.\n - Hypertension\n - Hyperlipidemia\n - Gastritis, on PPI\n - Osteoporosis, with history of multiple compression and rib\n fractures from coughing\n - History of thrush/ esophagitis steroid therapy\n - Depression\n - Tremor\n Mother with DM, father with pancreatic cancer.\n Occupation: retired\n Drugs: none\n Tobacco: 30 pack-years, quit in \n Alcohol: none\n Other: lives with her daughter \n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Myalgias\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 12:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 119 (118 - 119) bpm\n BP: 114/59(72) {114/59(72) - 114/59(72)} mmHg\n RR: 26 (26 - 26) insp/min\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, CPAP mask\n ABG: 7.34/42/68//-2\n Physical Examination\n General Appearance: No(t) Well nourished, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diffuse, Diminished: , Rhonchorous: occassional)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 7\n 90\n 5.3\n 138\n 45.8\n 12.4\n [image002.jpg]\n \n 2:33 A2/11/ 10:20 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.4\n Hct\n 45.8\n Plt\n 563\n TC02\n 24\n Assessment and Plan\n 62 y/o F with PMHx of COPD and Pulm HTN who presents with SOB, cough\n and increased sputum production likely consistent with COPD\n exacerbation.\n # COPD: Pt with h/o severe obstructive lung disease c/w COPD. Has h/o\n multiple intubations and is at high risk now given recent course of\n steroids. CXR does not appear to indicate concurrent PNA. Initial ABG\n on CPAP 3L 7.34/42/68/24.\n - continue CPAP as tolerated, c/s BiPAP if becomes severely hypercarbic\n - solumedrol 125mg IV daily (pt with recent steroid taper)\n - start Azithromycin\n - d/c levofloxacin -> no evidence of pneumonia on exam or CXR\n - continue nebs\n - home COPD meds\n .\n # CAD: Stable, last EF 50-55%.\n - cont plavix, lisinopril, statin\n .\n # Hypertension: Stable on home ACEI.\n - cont lisinopril\n .\n # Depression: Stable on home regimen.\n - cont nortriptyline, paroxetine\n .\n # FEN: Maintenance IVF, replete electrolytes, cardiac diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: 2 peripherals\n .\n # Code: FULL CODE\n .\n # Communication: Patient\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:56 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2206-01-09 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 365034, "text": "Chief Complaint: Shortness of breath, increased sputum production\n HPI:\n 62 y/o F with PMHx of CAD s/p MI, COPD on 2L home O2 and IgA deficiency\n who presents with progressive SOB over last 4-5 days with cough and\n increased sputum production. Pt recently finished prednisone taper on\n . Pt with multiple sick contacts recently, including \"strep\n throat.\" She denied CP, abd pain, nausea, vomiting, diarrhea, fever and\n chills.\n .\n In the ED, initial vs were: T 98.1 P 110 BP 121/79 R 38 sats 100% on\n NRB. Patient was given Solumedrol 125mg IV, Levofloxacin 750mg, and\n stacked nebs. BP was noted to trend down to 90/50s and pt received NS\n 500cc bolus, repeat bp 104/62. Pt was mentating okay on CPAP.\n .\n On arrival to the ICU pt was breathing more comfortably on CPAP. Pt\n felt symptomatically improved although still appeared tachypneic.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66%\n (61% and 40% predicted respectively); intubated several times in\n the past. on 2L home O2.\n - IgA deficiency, was on IV gamma globulin with Dr. .\n - CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in\n (chest pain with left arm discomfort). Cath in with\n PTCA/stent to LCx. Cath in with stent placement to RCA\n and LCx.\n - Hypertension\n - Hyperlipidemia\n - Gastritis, on PPI\n - Osteoporosis, with history of multiple compression and rib\n fractures from coughing\n - History of thrush/ esophagitis steroid therapy\n - Depression\n - Tremor\n Mother with DM, father with pancreatic cancer.\n Occupation: retired\n Drugs: none\n Tobacco: 30 pack-years, quit in \n Alcohol: none\n Other: lives with her daughter \n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Myalgias\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 12:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 119 (118 - 119) bpm\n BP: 114/59(72) {114/59(72) - 114/59(72)} mmHg\n RR: 26 (26 - 26) insp/min\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, CPAP mask\n ABG: 7.34/42/68//-2\n Physical Examination\n General Appearance: No(t) Well nourished, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diffuse, Diminished: , Rhonchorous: occassional)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 7\n 90\n 5.3\n 138\n 45.8\n 12.4\n \n 2:33 A2/11/ 10:20 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.4\n Hct\n 45.8\n Plt\n 563\n TC02\n 24\n Assessment and Plan\n 62 y/o F with PMHx of COPD and Pulm HTN who presents with SOB, cough\n and increased sputum production likely consistent with COPD\n exacerbation.\n # COPD: Pt with h/o severe obstructive lung disease c/w COPD. Has h/o\n multiple intubations and is at high risk now given recent course of\n steroids. CXR does not appear to indicate concurrent PNA. Initial ABG\n on CPAP 3L 7.34/42/68/24.\n - continue CPAP as tolerated, c/s BiPAP if becomes severely hypercarbic\n - solumedrol 125mg IV daily (pt with recent steroid taper)\n - start Azithromycin\n - d/c levofloxacin -> no evidence of pneumonia on exam or CXR\n - continue nebs\n - home COPD meds\n .\n # Anion-Gap Acidosis: Unclear etiology, pt with no h/o or risk factors\n for toxic ingestions, pt not overtly uremic, pt not diabetic, unlikely\n EtOH/starvation ketoacidosis.\n - will hydrate\n - recheck lytes after hydration\n - could check serum osm gap\n .\n # CAD: Stable, last EF 50-55%.\n - cont plavix, lisinopril, statin\n .\n # Hypertension: Stable on home ACEI.\n - cont lisinopril\n .\n # Depression: Stable on home regimen.\n - cont nortriptyline, paroxetine\n .\n # FEN: Maintenance IVF, replete electrolytes, cardiac diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: 2 peripherals\n .\n # Code: FULL CODE\n .\n # Communication: Patient\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:56 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ATTENDING ADDENDUM:\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan\n Key Points:\n 62 yo woman with severe chronic respiratory failure with COPD and\n kyphoscoliosis, on home O2, admitted with COPD exacerbation. Much\n improved after BiPAP overnight, now on 3L NC. Azithromycin, prednisone,\n nebs.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:11 ------\n" }, { "category": "Nursing", "chartdate": "2206-01-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 365037, "text": "62F presents with progressive SOB over last 4-5 days with cough and\n increased sputum production. Recently finished prednisone taper on .\n Has had with multiple sick contacts recently, including \"strep throat.\"\n Was given Solumedrol 125mg IV, Levofloxacin 750mg, and stacked nebs.\n BP was noted to trend down to 90/50s and pt received NS 500cc bolus,\n repeat bp 104/62\n On arrival to the ICU pt was breathing more comfortably on CPAP. Felt\n symptomatically improved although still appeared tachypneic. Off Cpap\n all night on 3L NC. MICU unable to obtain an ABG throughout night. Pt\n mentating okay.\nPMH:\n- COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61% and 40% pred\nicted respectively); intubated several times in the past. on 2L home O2.\n- IgA deficiency was on IV gamma globulin with Dr. .\n- CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in (chest pai\nn with left arm discomfort). Cath in with PTCA/stent to LCx. Cath in \n05 with stent placement to RCA and LCx.\n- Hypertension\n- Hyperlipidemia\n- Gastritis, on PPI\n- Osteoporosis, with history of multiple compression and rib fractures from \n\n- Severe kyphosis\n- History of thrush/ esophagitis steroid therapy\n- Depression\n- Tremor\nShe lives with her daughter, , son-in-law and 3 grand-children. She is\na widow. She is an ex-smoker, with\nabout a 30-pack-year smoking history, quit in . Uses a cane and walker to a\nmbulate.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Comfortable on 3L NC. RR24-32. LS at times clear, tight w/ I/E\n wheezing and course rhonchi after neb treatment.\n Hr ST in the 100\n Course congested cough. Expectorating small amount thick green sputum.\n Action:\n Nebs given Q2-4 hrs.\n Response:\n Lungs clear but diminished.\n Plan:\n Continue nebs as needed.\n Send sputum spec when available.\n Transfer to floor when bed avail.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ASTHMA;COPD EXACEREBATION\n Code status:\n Full code\n Height:\n 64 Inch\n Admission weight:\n 45 kg\n Daily weight:\n Allergies/Reactions:\n Tetracyclines\n Unknown;\n Precautions: Contact\n PMH: Asthma, COPD\n CV-PMH: CAD, Hypertension, PVD\n Additional history: Depression. Osetoporotic fractures. Empysema with\n asthma.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:59\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 2,543 mL\n 24h total out:\n 460 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 12:42 AM\n Potassium:\n 4.6 mEq/L\n 12:42 AM\n Chloride:\n 92 mEq/L\n 12:42 AM\n CO2:\n 26 mEq/L\n 12:42 AM\n BUN:\n 26 mg/dL\n 12:42 AM\n Creatinine:\n 1.0 mg/dL\n 12:42 AM\n Glucose:\n 125 mg/dL\n 12:42 AM\n Hematocrit:\n 39.4 %\n 12:42 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Sicu A 696\n Transferred to: CC-705\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2206-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 364930, "text": "Chief Complaint: Shortness of breath, increased sputum production\n HPI:\n 62 y/o F with PMHx of CAD s/p MI, COPD on 2L home O2 and IgA deficiency\n who presents with progressive SOB over last 4-5 days with cough and\n increased sputum production. Pt recently finished prednisone taper on\n . Pt with multiple sick contacts recently, including \"strep\n throat.\" She denied CP, abd pain, nausea, vomiting, diarrhea, fever and\n chills.\n .\n In the ED, initial vs were: T 98.1 P 110 BP 121/79 R 38 sats 100% on\n NRB. Patient was given Solumedrol 125mg IV, Levofloxacin 750mg, and\n stacked nebs. BP was noted to trend down to 90/50s and pt received NS\n 500cc bolus, repeat bp 104/62. Pt was mentating okay on CPAP.\n .\n On arrival to the ICU pt was breathing more comfortably on CPAP. Pt\n felt symptomatically improved although still appeared tachypneic.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n tachypneic on arrival to icu. Refused to wear cpap. Lungs coarse,\n tight, inspiratory and expiratory wheezes. Taken off nrb and placed on\n 3 liters nc. M.d. attempted abg, unable to draw.\n Action:\n albuterol and iatrovent neb treatments q 2/hours. Hob maintained at 45\n degrees and greater.\n Response:\n lung sounds improved. Respiratory rate decreased. O2 sats93-95%. Less\n effort in breathing.\n Plan:\n continue neb treatments as needed.\n" }, { "category": "Nursing", "chartdate": "2206-01-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 365023, "text": "PMH:\n- COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61% and 40% pred\nicted respectively); intubated several times in the past. on 2L home O2.\n- IgA deficiency was on IV gamma globulin with Dr. .\n- CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in (chest pai\nn with left arm discomfort). Cath in with PTCA/stent to LCx. Cath in \n05 with stent placement to RCA and LCx.\n- Hypertension\n- Hyperlipidemia\n- Gastritis, on PPI\n- Osteoporosis, with history of multiple compression and rib fractures from \n\n- Severe kyphosis\n- History of thrush/ esophagitis steroid therapy\n- Depression\n- Tremor\nShe lives with her daughter, , son-in-law and 3\ngrand-children. She is a widow. She is an ex-smoker, with\nabout a 30-pack-year smoking history, quit in . Uses a cane and walker to a\nmbulate.\n" }, { "category": "Nursing", "chartdate": "2206-01-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 365026, "text": "62F presents with progressive SOB over last 4-5 days with cough and\n increased sputum production. Recently finished prednisone taper on .\n Has had with multiple sick contacts recently, including \"strep throat.\"\nPMH:\n- COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61% and 40% pred\nicted respectively); intubated several times in the past. on 2L home O2.\n- IgA deficiency was on IV gamma globulin with Dr. .\n- CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in (chest pai\nn with left arm discomfort). Cath in with PTCA/stent to LCx. Cath in \n05 with stent placement to RCA and LCx.\n- Hypertension\n- Hyperlipidemia\n- Gastritis, on PPI\n- Osteoporosis, with history of multiple compression and rib fractures from \n\n- Severe kyphosis\n- History of thrush/ esophagitis steroid therapy\n- Depression\n- Tremor\nShe lives with her daughter, , son-in-law and 3 grand-children. She is\na widow. She is an ex-smoker, with\nabout a 30-pack-year smoking history, quit in . Uses a cane and walker to a\nmbulate.\n" }, { "category": "Nursing", "chartdate": "2206-01-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 365029, "text": "62F presents with progressive SOB over last 4-5 days with cough and\n increased sputum production. Recently finished prednisone taper on .\n Has had with multiple sick contacts recently, including \"strep throat.\"\n Was given Solumedrol 125mg IV, Levofloxacin 750mg, and stacked nebs.\n BP was noted to trend down to 90/50s and pt received NS 500cc bolus,\n repeat bp 104/62\n On arrival to the ICU pt was breathing more comfortably on CPAP. Felt\n symptomatically improved although still appeared tachypneic. Off Cpap\n all night on 3L NC. MICU unable to obtain an ABG throughout night. Pt\n mentating okay.\nPMH:\n- COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61% and 40% pred\nicted respectively); intubated several times in the past. on 2L home O2.\n- IgA deficiency was on IV gamma globulin with Dr. .\n- CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in (chest pai\nn with left arm discomfort). Cath in with PTCA/stent to LCx. Cath in \n05 with stent placement to RCA and LCx.\n- Hypertension\n- Hyperlipidemia\n- Gastritis, on PPI\n- Osteoporosis, with history of multiple compression and rib fractures from \n\n- Severe kyphosis\n- History of thrush/ esophagitis steroid therapy\n- Depression\n- Tremor\nShe lives with her daughter, , son-in-law and 3 grand-children. She is\na widow. She is an ex-smoker, with\nabout a 30-pack-year smoking history, quit in . Uses a cane and walker to a\nmbulate.\n" }, { "category": "Nursing", "chartdate": "2206-01-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 365030, "text": "62F presents with progressive SOB over last 4-5 days with cough and\n increased sputum production. Recently finished prednisone taper on .\n Has had with multiple sick contacts recently, including \"strep throat.\"\n Was given Solumedrol 125mg IV, Levofloxacin 750mg, and stacked nebs.\n BP was noted to trend down to 90/50s and pt received NS 500cc bolus,\n repeat bp 104/62\n On arrival to the ICU pt was breathing more comfortably on CPAP. Felt\n symptomatically improved although still appeared tachypneic. Off Cpap\n all night on 3L NC. MICU unable to obtain an ABG throughout night. Pt\n mentating okay.\nPMH:\n- COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61% and 40% pred\nicted respectively); intubated several times in the past. on 2L home O2.\n- IgA deficiency was on IV gamma globulin with Dr. .\n- CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in (chest pai\nn with left arm discomfort). Cath in with PTCA/stent to LCx. Cath in \n05 with stent placement to RCA and LCx.\n- Hypertension\n- Hyperlipidemia\n- Gastritis, on PPI\n- Osteoporosis, with history of multiple compression and rib fractures from \n\n- Severe kyphosis\n- History of thrush/ esophagitis steroid therapy\n- Depression\n- Tremor\nShe lives with her daughter, , son-in-law and 3 grand-children. She is\na widow. She is an ex-smoker, with\nabout a 30-pack-year smoking history, quit in . Uses a cane and walker to a\nmbulate.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Comfortable on 3L NC. RR24-32. LS at times clear, tight w/ I/E\n wheezing and course rhonchi after neb treatment.\n Hr ST in the 100\n Course congested cough. Expectorating small amount thick green sputum.\n Action:\n Nebs given Q2-4 hrs.\n Response:\n Lungs clear but diminished.\n Plan:\n Continue nebs as needed.\n Send sputum spec when available.\n Transfer to floor when bed avail.\n" }, { "category": "Nursing", "chartdate": "2206-01-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 365025, "text": "62F presents with progressive SOB over last 4-5 days with cough and\n increased sputum production. Recently finished prednisone taper on .\n Has had with multiple sick contacts recently, including \"strep throat.\"\nPMH:\n- COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61% and 40% pred\nicted respectively); intubated several times in the past. on 2L home O2.\n- IgA deficiency was on IV gamma globulin with Dr. .\n- CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in (chest pai\nn with left arm discomfort). Cath in with PTCA/stent to LCx. Cath in \n05 with stent placement to RCA and LCx.\n- Hypertension\n- Hyperlipidemia\n- Gastritis, on PPI\n- Osteoporosis, with history of multiple compression and rib fractures from \n\n- Severe kyphosis\n- History of thrush/ esophagitis steroid therapy\n- Depression\n- Tremor\nShe lives with her daughter, , son-in-law and 3 grand-children. She is\na widow. She is an ex-smoker, with\nabout a 30-pack-year smoking history, quit in . Uses a cane and walker to a\nmbulate.\n" }, { "category": "Physician ", "chartdate": "2206-01-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 364907, "text": "Chief Complaint: Shortness of breath, increased sputum production\n HPI:\n 62 y/o F with PMHx of CAD s/p MI, COPD on 2L home O2 and IgA deficiency\n who presents with progressive SOB over last 4-5 days with cough and\n increased sputum production. Pt recently finished prednisone taper on\n . Pt with multiple sick contacts recently, including \"strep\n throat.\" She denied CP, abd pain, nausea, vomiting, diarrhea, fever and\n chills.\n .\n In the ED, initial vs were: T 98.1 P 110 BP 121/79 R 38 sats 100% on\n NRB. Patient was given Solumedrol 125mg IV, Levofloxacin 750mg, and\n stacked nebs. BP was noted to trend down to 90/50s and pt received NS\n 500cc bolus, repeat bp 104/62. Pt was mentating okay on CPAP.\n .\n On arrival to the ICU pt was breathing more comfortably on CPAP. Pt\n felt symptomatically improved although still appeared tachypneic.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66%\n (61% and 40% predicted respectively); intubated several times in\n the past. on 2L home O2.\n - IgA deficiency, was on IV gamma globulin with Dr. .\n - CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in\n (chest pain with left arm discomfort). Cath in with\n PTCA/stent to LCx. Cath in with stent placement to RCA\n and LCx.\n - Hypertension\n - Hyperlipidemia\n - Gastritis, on PPI\n - Osteoporosis, with history of multiple compression and rib\n fractures from coughing\n - History of thrush/ esophagitis steroid therapy\n - Depression\n - Tremor\n Mother with DM, father with pancreatic cancer.\n Occupation: retired\n Drugs: none\n Tobacco: 30 pack-years, quit in \n Alcohol: none\n Other: lives with her daughter \n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Myalgias\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 12:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 119 (118 - 119) bpm\n BP: 114/59(72) {114/59(72) - 114/59(72)} mmHg\n RR: 26 (26 - 26) insp/min\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, CPAP mask\n ABG: 7.34/42/68//-2\n Physical Examination\n General Appearance: No(t) Well nourished, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diffuse, Diminished: , Rhonchorous: occassional)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 7\n 90\n 5.3\n 138\n 45.8\n 12.4\n [image002.jpg]\n \n 2:33 A2/11/ 10:20 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.4\n Hct\n 45.8\n Plt\n 563\n TC02\n 24\n Assessment and Plan\n 62 y/o F with PMHx of COPD and Pulm HTN who presents with SOB, cough\n and increased sputum production likely consistent with COPD\n exacerbation.\n # COPD: Pt with h/o severe obstructive lung disease c/w COPD. Has h/o\n multiple intubations and is at high risk now given recent course of\n steroids. CXR does not appear to indicate concurrent PNA. Initial ABG\n on CPAP 3L 7.34/42/68/24.\n - continue CPAP as tolerated, c/s BiPAP if becomes severely hypercarbic\n - solumedrol 125mg IV daily (pt with recent steroid taper)\n - start Azithromycin\n - d/c levofloxacin -> no evidence of pneumonia on exam or CXR\n - continue nebs\n - home COPD meds\n .\n # Anion-Gap Acidosis: Unclear etiology, pt with no h/o or risk factors\n for toxic ingestions, pt not overtly uremic, pt not diabetic, unlikely\n EtOH/starvation ketoacidosis.\n - will hydrate\n - recheck lytes after hydration\n - could check serum osm gap\n .\n # CAD: Stable, last EF 50-55%.\n - cont plavix, lisinopril, statin\n .\n # Hypertension: Stable on home ACEI.\n - cont lisinopril\n .\n # Depression: Stable on home regimen.\n - cont nortriptyline, paroxetine\n .\n # FEN: Maintenance IVF, replete electrolytes, cardiac diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: 2 peripherals\n .\n # Code: FULL CODE\n .\n # Communication: Patient\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:56 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2206-01-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 364905, "text": "Chief Complaint: Shortness of breath, increased sputum production\n HPI:\n 62 y/o F with PMHx of CAD s/p MI, COPD on 2L home O2 and IgA deficiency\n who presents with progressive SOB over last 4-5 days with cough and\n increased sputum production. Pt recently finished prednisone taper on\n . Pt with multiple sick contacts recently, including \"strep\n throat.\" She denied CP, abd pain, nausea, vomiting, diarrhea, fever and\n chills.\n .\n In the ED, initial vs were: T 98.1 P 110 BP 121/79 R 38 sats 100% on\n NRB. Patient was given Solumedrol 125mg IV, Levofloxacin 750mg, and\n stacked nebs. BP was noted to trend down to 90/50s and pt received NS\n 500cc bolus, repeat bp 104/62. Pt was mentating okay on CPAP.\n .\n On arrival to the ICU pt was breathing more comfortably on CPAP. Pt\n felt symptomatically improved although still appeared tachypneic.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Tetracyclines\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - COPD, last PFTs with FVC 1.72, FEV1 0.82, FEV1/FVC 66%\n (61% and 40% predicted respectively); intubated several times in\n the past. on 2L home O2.\n - IgA deficiency, was on IV gamma globulin with Dr. .\n - CAD s/p MIs in (flu symptoms), (jaw pain), NSTEMI in\n (chest pain with left arm discomfort). Cath in with\n PTCA/stent to LCx. Cath in with stent placement to RCA\n and LCx.\n - Hypertension\n - Hyperlipidemia\n - Gastritis, on PPI\n - Osteoporosis, with history of multiple compression and rib\n fractures from coughing\n - History of thrush/ esophagitis steroid therapy\n - Depression\n - Tremor\n Mother with DM, father with pancreatic cancer.\n Occupation: retired\n Drugs: none\n Tobacco: 30 pack-years, quit in \n Alcohol: none\n Other: lives with her daughter \n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: Cough, Dyspnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Myalgias\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 12:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 119 (118 - 119) bpm\n BP: 114/59(72) {114/59(72) - 114/59(72)} mmHg\n RR: 26 (26 - 26) insp/min\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, CPAP mask\n ABG: 7.34/42/68//-2\n Physical Examination\n General Appearance: No(t) Well nourished, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diffuse, Diminished: , Rhonchorous: occassional)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 7\n 90\n 5.3\n 138\n 45.8\n 12.4\n [image002.jpg]\n \n 2:33 A2/11/ 10:20 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.4\n Hct\n 45.8\n Plt\n 563\n TC02\n 24\n Assessment and Plan\n 62 y/o F with PMHx of COPD and Pulm HTN who presents with SOB, cough\n and increased sputum production likely consistent with COPD\n exacerbation.\n # COPD: Pt with h/o severe obstructive lung disease c/w COPD. Has h/o\n multiple intubations and is at high risk now given recent course of\n steroids. CXR does not appear to indicate concurrent PNA. Initial ABG\n on CPAP 3L 7.34/42/68/24.\n - continue CPAP as tolerated, c/s BiPAP if becomes severely hypercarbic\n - solumedrol 125mg IV daily (pt with recent steroid taper)\n - start Azithromycin\n - d/c levofloxacin -> no evidence of pneumonia on exam or CXR\n - continue nebs\n - home COPD meds\n .\n # CAD: Stable, last EF 50-55%.\n - cont plavix, lisinopril, statin\n .\n # Hypertension: Stable on home ACEI.\n - cont lisinopril\n .\n # Depression: Stable on home regimen.\n - cont nortriptyline, paroxetine\n .\n # FEN: Maintenance IVF, replete electrolytes, cardiac diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: 2 peripherals\n .\n # Code: FULL CODE\n .\n # Communication: Patient\n .\n # Disposition: pending above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:56 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "ECG", "chartdate": "2206-01-08 00:00:00.000", "description": "Report", "row_id": 127455, "text": "Sinus tachycardia\nShort P-R interval\nPossible anterior infarct - age undetermined\nInferior/lateral ST-T changes are nonspecific\nPoor R wave progression\n\n" }, { "category": "Radiology", "chartdate": "2206-01-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1062253, "text": " 7:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with tachypnea\n REASON FOR THIS EXAMINATION:\n eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n Comparison is made with a prior study from .\n\n CLINICAL HISTORY: 62-year-old woman with tachypnea. Evaluate for acute\n process.\n\n FINDINGS: Single AP upright portable chest radiograph is obtained.\n Hyperlucent and hyperinflated lungs are noted compatible with patient's\n underlying emphysema, as seen on prior CT chest from . Kyphotic\n posture results in a somewhat limited evaluation. There is no definite\n evidence of pneumonia or CHF. No pleural effusion or pneumothorax is seen.\n Cardiomediastinal silhouette appears stable with an unfolded thoracic aorta\n again noted. Bilateral rib cage deformities are again noted.\n\n IMPRESSION: No evidence of pneumonia. Chronic changes as described.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2206-01-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1062299, "text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate, effusion, edema\n Admitting Diagnosis: ASTHMA;COPD EXACEREBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with COPD exacerbation\n REASON FOR THIS EXAMINATION:\n ?infiltrate, effusion, edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD exacerbation. Questionable infiltrate, effusion, edema.\n\n COMPARISON: .\n\n FINDINGS: Increased interstitial markings in both lung bases are noted, new\n since prior study and likely represent mild interstitial edema. The\n cardiomediastinal silhouette is stable. There is no pneumothorax,\n consolidation, pleural effusions. Severe emphysema is again noted. Bilateral\n rib cage deformities are again seen.\n\n IMPRESSION: Increased interstitial markings in both lung bases likely\n represent mild interstitial edema.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2103-03-29 00:00:00.000", "description": "ART DUP EXT LOW/BILAT COMP", "row_id": 822830, "text": " 1:17 PM\n ART DUP EXT LOW/BILAT COMP Clip # \n Reason: BILAT GROIN BRUITS\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CAD s/p cath yesterday noted to have L and R groin\n bruit.\n REASON FOR THIS EXAMINATION:\n r/o pseudoaneurysm or AVF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 80-year-old female status post cardiac catheterization, noted\n to have both left and right groin bruits.\n\n Son interrogation of both the right and left groins was performed and\n demonstrates normal arterial and venous wave forms, without evidence for\n pseudoaneurysms or AV fistulas.\n\n IMPRESSION: No evidence for vascular abnormality in the groins bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2103-03-26 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 822562, "text": " 10:17 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CAD\n REASON FOR THIS EXAMINATION:\n assess cardiac status and pre op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop for coronary bypass surgery.\n\n PA AND LATERAL RADIOGRAPH: No prior studies for comparison.\n\n The heart is normal in size. The aorta is somewhat ectatic and calcified.\n There is a patchy density in the right middle lobe and linear atelectasis at\n both lung bases. There are no effusions or focal consolidations. The\n pulmonary vasculature is normal. There is probable bronchiectasis in both\n lower lobes. The osseous structures are demineralized with degenerative\n changes seen throughout the thoracic spine. The patient is moderately\n kyphotic.\n\n IMPRESSION: No pneumonia or heart failure. Bibasilar atelectasis. Right\n middle lobe density is likely due to atelectasis, though a pneumonia can not\n be excluded. Clinical correlation recommended.\n\n" }, { "category": "Radiology", "chartdate": "2103-03-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 822681, "text": " 9:10 AM\n CHEST (PA & LAT) Clip # \n Reason: re-eval RML opacity\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CAD\n\n REASON FOR THIS EXAMINATION:\n re-eval RML opacity\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Coronary artery disease. Re-evaluate right middle lobe opacity.\n\n FINDINGS: Standard PA & left lateral views. Comparison study dated . There is again evidence of collapse and consolidation of the right middle\n lobe, slightly improved since the prior study. There is associated\n consolidation and some collapse of the basal segments of the right lower lobe.\n A linear atelectasis is noted in the anterior portion of the right upper lobe.\n These findings are not significantly changed since the examination of 2 days\n earlier. The heart is not significantly enlarged. The aorta is slightly\n calcified and tortuous. The pulmonary vessels do not suggest cardiac failure.\n There is no evidence of pleural effusion on either side. The hila and\n mediastinum are unremarkable. The thoracolumbar scoliosis is noted, concave to\n the right. This might account for the different projections of the patient's\n breast profiles. Alternatively, is there any history of partial mastectomy of\n the right breast?\n\n IMPRESSION: Essentially unchanged atelectasis and consolidation involving the\n right middle lobe and right lower lobe and to a lesser extent the right upper\n lobe. Delayed follow up images are recommended to evaluate these areas\n further. If necessary, CT examination should be considered.\n\n" }, { "category": "ECG", "chartdate": "2103-03-29 00:00:00.000", "description": "Report", "row_id": 189109, "text": "Sinus rhythm\nPoor R wave progression\nMinor nonspecific ST-T wave abnormalities\n\n" }, { "category": "ECG", "chartdate": "2103-03-29 00:00:00.000", "description": "Report", "row_id": 189110, "text": "Sinus rhythm\nPoor R wave progression\nMinor nonspecific ST-T wave abnormalities\n\n" }, { "category": "ECG", "chartdate": "2103-03-28 00:00:00.000", "description": "Report", "row_id": 189111, "text": "Sinus rhythm\nPoor R wave progression\nNonspecific ST-T abnormalities\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2103-03-26 00:00:00.000", "description": "Report", "row_id": 189112, "text": "Sinus tachycardia\nPoor R wave progression - possible left ventricular hypertrophy (aVL = 13\nmillimeter)\nLateral ST changes are nonspecific\nNo previous tracing\n\n" }, { "category": "Nursing/other", "chartdate": "2103-03-29 00:00:00.000", "description": "Report", "row_id": 1481924, "text": "neuro: alert and oriented x 3. denies pain. mae to command.\ncv/resp no c/o chest pain. no resp distress. bp stable. hr wnl. increased hr when nauseated. ekg done at aprox 1:20am. when pt. c/o nausea for the second time and noted to be slightly tachycardic. integrelin gtt infusing since 4pm in the cath lab at 1mcg/kg/min.ivf 1/2 ns at 100cc/hr all via left peripheral\ngi/gu refusing solid food. nauseated at 2400 and again at 0200. zophran 2mg given x 2. foley to gravity. marginal uop clear yellow. no stools.\ninteg right breast dsg dry and inact. right groin sheaths pulled by cath lab personel. site c-clamped and frequently checeked. right groin area clean and dry with no hematoma or eccymosis. pt. is remaining flat in bed and tol well. sheath pulled at aprox 9pm.\nc/o of occ hip pain relieved by moving hips slightly on pull sheet.\n" } ]

[ { "category": "Radiology", "chartdate": "2170-03-09 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 952038, "text": " 8:55 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: with gadalidium per Neurology. please assess for leukoenceph\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year M s/p liver txp pod 6 now with recurrent seizures\n REASON FOR THIS EXAMINATION:\n with gadalidium per Neurology. please assess for leukoencephalopathy or other\n pathology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 68-year-old male status post liver transplant with new onset\n seizures.\n\n No prior comparison exams available.\n\n TECHNIQUE: Multiplanar T1 and T2-weighted brain imaging sequences with\n diffusion-weighted and post-gadolinum sequences were obtained. MRA of the\n Circle of was also obtained.\n\n HEAD MRI:\n\n FINDINGS: No intracranial mass lesion, hydrocephalus, shift of normally\n midline structures, minor or major vascular territorial infarct is apparent.\n Multiple small high signal lesions within the deep white matter,\n periventricular white matter, left posterior occipital lobe and deep white\n matter within the left frontal lobe are consistent with small vessel infarcts.\n Old lacunar infarcts are also identified within the cerebellar hemispheres\n bilaterally. There is no susceptibility artifact to suggest underlying\n hemorrhage and no enhancing masses are identified. Surrounding osseous and\n soft tissue structures are unremarkable. Major vascular flow patterns of the\n brain are normal.\n\n MRA CIRCLE OF :\n\n 3D time of flight imaging with multiplanar reconstructions were obtained.\n Major tributaries of the Circle of are patent. No area of significant\n stenosis or aneurysmal dilatation. Within normal limits of the coverage of\n the study, no sign of AV malformation is apparent.\n\n IMPRESSION:\n\n 1) No evidence of acute infarct, hemorrhage, or enhancing masses to explain\n patient's current seizures. Changes from chronic small vessel ischemic\n disease.\n\n 2) Normal appearing MRA of the Circle of .\n\n\n (Over)\n\n 8:55 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: with gadalidium per Neurology. please assess for leukoenceph\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2170-03-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 951994, "text": " 8:07 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: pt with seizure activity and post ictal confusion please ass\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p liver TXP POD 5\n REASON FOR THIS EXAMINATION:\n pt with seizure activity and post ictal confusion please asses for pathology of\n CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man status post liver transplant, postop day #5, now\n with seizure activity.\n\n No prior studies for comparison.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is no hemorrhage, mass effect, shift of the normally midline\n structures, or major vascular territorial infarct. The -white matter\n differentiation is preserved. There is no hydrocephalus. An ovoid\n hypodensity within the left cerebellar hemisphere likely represents a chronic\n lacunar infarct. The osseous structures are unremarkable. The paranasal\n sinuses and mastoid air cells are well aerated.\n\n IMPRESSION:\n 1. No hemorrhage, cerebral edema or mass effect.\n\n 2. Chronic lacunar infarct in the left cerebellar hemisphere.\n\n" }, { "category": "Radiology", "chartdate": "2170-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 952008, "text": " 4:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for infiltarte\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p liver txp pod 6\n\n REASON FOR THIS EXAMINATION:\n please assess for infiltarte\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant, post-op day six. Evaluate for\n infiltrate.\n\n COMPARISON: .\n\n SINGLE UPRIGHT AP CHEST RADIOGRAPH: No evidence of pneumonia. Low lung\n volumes are present. Small bilateral pleural effusions and bibasilar\n atelectasis are unchanged. The heart is stablely enlarged. Mediastinal and\n hilar contours are normal. Right IJ line terminates in the right atrium,\n unchanged compared to five days prior. No evidence of pneumothorax.\n\n IMPRESSION: No evidence for pneumonia. Bibasilar effusions and atelectasis\n are unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2170-03-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 951328, "text": " 7:06 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ptx\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with r ij\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Right IJ line placed, check for position or pneumothorax.\n\n Sheath and line has been placed in the right IJ. The tip of the Swan-Ganz\n lies in a branch within the right lower lobe. There is no pneumothorax. The\n endotracheal tube lies 3.9 cm from the carinal angle. Nasogastric tube is\n present with the tip in the stomach. Atelectasis at both bases is present\n particularly at the left.\n\n IMPRESSION: Tip of Swan-Ganz catheter in right lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-03-04 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 951384, "text": " 10:19 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: LIVER TRANSPLANT ? FLOWS\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with liver transplant\n REASON FOR THIS EXAMINATION:\n flows\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old male with liver transplant.\n\n GRAYSCALE AND DOPPLER ULTRASOUND OF THE TRANSPLANT LIVER: Comparison is made\n with the prior CT dated , and ultrasound dated . The\n patient is post-liver transplant. No focal liver lesion or intrahepatic\n ductal dilatation is noted in the visualized portion of the liver. Patency\n and appropriate waveforms are demonstrated in main portal vein, anterior and\n posterior right portal veins, left portal vein, main and bilateral hepatic\n arteries and three hepatic veins.\n\n IMPRESSION: Post transplant liver. Patent vessels with appropriate\n waveforms.\n\n" }, { "category": "Radiology", "chartdate": "2170-03-03 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 951274, "text": " 9:55 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: LIVER FAILURE\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with HCC, cirrhosis. Preop CXR for liver transplant.\n REASON FOR THIS EXAMINATION:\n preop cxr\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Hepatitis C cirrhosis. Pre-operative chest radiograph prior to\n liver transplant.\n\n PA AND LATERAL CHEST: Comparison is made to chest radiographs from , . Cardiac size is within normal limits. There is no CHF or\n consolidation. There is minor left lower lobe atelectasis. There is no\n pleural effusion. Osseous structures are unchanged in appearance, again\n demonstrating increased thoracic kyphosis.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-03-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 951398, "text": " 1:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: rewired R IJ central line, ? PTX and positioning\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with r ij\n\n REASON FOR THIS EXAMINATION:\n rewired R IJ central line, ? PTX and positioning\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n INDICATION: Right IJ line.\n\n A single AP view of the chest is obtained at 13:33 hours and is\n compared with the prior day's radiograph. The right-sided vascular sheath has\n been removed and a right-sided IJ line inserted. The tip of this appears to\n overlie the right atrium. Patchy atelectasis is seen at the left base\n together with a small left pleural effusion, not markedly changed since prior\n examination. The patient has been extubated. Lung volumes remain low.\n\n IMPRESSION:\n\n Persistent bibasilar atelectasis, more marked on the left side, together with\n a small left pleural effusion. Right-sided IJ line has its tip likely in the\n right atrium. There is no evidence of pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2170-03-03 00:00:00.000", "description": "Report", "row_id": 201125, "text": "Sinus rhythm. Low precordial lead QRS voltage. Modest T wave changes. Findings\nare non-specific and clinical correlation is suggested. Since the previous\ntracing of findings as described are now present.\n\n" }, { "category": "Nursing/other", "chartdate": "2170-03-04 00:00:00.000", "description": "Report", "row_id": 1283647, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and on PS settings at this time. Switched to PS at 0430. Tolerating well. Vt=600, RR=, Ve=8-9 liters. RSBI completed on PS 5=32. Plan to extubate this AM.\n\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2170-03-04 00:00:00.000", "description": "Report", "row_id": 1283648, "text": "SICU NPN\nS-\"Is my inciscion big.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-A/O/X/3. Cooperative with care. Anxious at times. MAEs. HR 70-80s, NSR with no viewed ectopy. SBPs 150-170s. CVP 6-8. CCO catheter discontinued and TLC placed over a wire. Pulses palpable throughout. Neosynepherine remains off. Extubated without incident. Weaned to 3LNP and sating > 95%. Denies SOB. CDB fair. Post extubation ABG wnls. HUO remain marginal, 15-30cc/hr. IVF continue 125cc/hr, no further fluid boluses given this shift. OGT pulled and started on sip of clears/ice chips. Abd soft with hypoactive bowel sounds. Inciscion moderate drainage, changed this morning and drainage in small amounts. Transfused with 1u PLTs for PLTs < 100. PLTs count pending. No further transfusions this shift. Insulin infusion stopped and FS stable since and continues tapered dose of Solumedrol. Afebrile. No issues. Tacrolimus dosed for tonight.Family visiting for most of the day. Updated by RN and resident in regards to progress.\n\nA/P: Post op day 1 s/p liver tx doing well.\nMontior UO closely\nKeeping HCT > 30, INR < 1.5 and PLTs > 100\nLabs pending from 1700 draw\nPain medication as needed\n\n" }, { "category": "Nursing/other", "chartdate": "2170-03-04 00:00:00.000", "description": "Report", "row_id": 1283649, "text": "RESPIRATORY CARE: PT EXTUBATED THIS AM AFTER\nRSBI 30-40 AND A SUCCESSFUL SBT. EXTUBATED\nTO A 50 % AEROSOL. SPO2 100 %. WILL ENCOURAGE\nC/DB AND MONITOR RESPIRATORY STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2170-03-05 00:00:00.000", "description": "Report", "row_id": 1283650, "text": "0900-0700 NPN\nSee careview for details:\n\nAlert, oriented x 3. Anxious at times. MAE, following commands. C/O pain with turning/repositioning, occasional pain at rest, 2 mg morphine with good effect. Afebrile. SR HR 70's, no ectopy, SB with HR down to high 50's this am. Blood pressure 140's/60's, up to 160's with pain/anxiety but resolves without intervention. CVP 2-4. Lungs clear, no distress. SaO2>95% on 3LNC. Abd soflty distended, bowel sounds present, tolerating clear liquids. Foley with low urine output, ~20cc x 2 hrs this evening. Dr (SICU) aware, 20 mg lasix given per transplant recs. U/O increased slightly for several hours then decreased to ~30cc hr. Dr (transplant) notified and albumin given. Urine now >30cc/hr. ABD dsg cdi, JP x 2 with serosang output. Otherwise skin intact. Plan to monitor labs, monitor hemodynamics, monitor urine output and notify transplant team if decreased <30cc hr. Will advance activty today. Monitor pain level and treat as needed. Provide emotional support to patient and family.\n" }, { "category": "Nursing/other", "chartdate": "2170-03-03 00:00:00.000", "description": "Report", "row_id": 1283645, "text": "RESPIRATORY CARE: PT FROM OR TO SICU-B S/P LIVER TX.\n8.5 ORAL ETT 23 LIP. PLACED ON AC MODE 16/550/1.0/5 PEEP.\nABG PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2170-03-04 00:00:00.000", "description": "Report", "row_id": 1283646, "text": "1900-0700 NPN\nSee careview fo details:\n\nArrived from OR sedated on propofol. Weaned off and patient waking to voice and following commands inconsistantly. Moves all extremities. Pupils reactive, right pupil irregular, s/p cataract sugery. Morphine 2mg prn for pain with good effect. Afebrile. HR 100-110's initially, down to 80's after mult fluid bolus and volume given. SR, no ectopy noted. Neo at 1mcg/kg/min upon arrival, weaned off and sbp remains >110. PA with CCO, PA 35/22 initially, down to 22/13 this am. Dr aware. CVP 6-11. CO . Transfused with 2 units ffp for inr 2.2, down to 1.8 and additonal unit ffp given. INR 1.6 this am, transplant team aware, goal <1.5. Transfused with 1 unit PRBC for HCT 25, HCT 29 this am. Goal HCT >30. Transplant team aware. Lungs clear, on CMV at 50% 550x22. Rate increased from 16 after arrival from OR for elevated CO2. Breathing above vent only with discomfort/stimulation. Abd soft, OGT with minimal amt bilous output. Foley with adequate urine output. JP x 2, jp #2 with large amt output, tranplant team aware. Abd inc with moderate output, initial dsg intact. Otherwise skin intact. Blood sugars elevated >300, IVF changed from d51/2 ns to 1/2 ns. Cont on insulin gtts. Sicu and transplant team aware of elevated blood sugars. Plan to trial CPAP this am with goal to extubate this am. Live US this am. Cont to check labs, transfuse and replete as needed.\n" }, { "category": "Nursing/other", "chartdate": "2170-03-09 00:00:00.000", "description": "Report", "row_id": 1283651, "text": "Update\nSee careview for details...\nPt arrived from CT scan AAOx3, no seizure activity since being on 10, MAE, denies H/A, denies pain on arrival, med for back pain later in shift\n\nCV: NSR-NSB, BP stable, afebrile\n\nResp: Lungs clear, tol 4lnc O2, sats 98%\n\nGI: tol po, no N/V, abd soft, no BM\n\nGU: clear yellow urine via foley\n\nSkin: Abd inc. OTA, staples intact, scant serosang dng from site, JP dng serosang, mod amts\n\nWife and son updated by transplant team, emotional support given to pt and family\n\nPlan: MRI today, possible LP\n" }, { "category": "Nursing/other", "chartdate": "2170-03-09 00:00:00.000", "description": "Report", "row_id": 1283652, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-A+OX3. MAE. FOLLOWS COMMANDS. NORMAL/EQUAL STRENGTH. HAD MRI AND EEG TODAY. NO SZ ACTIVITY NOTED.\n\nCV-HR/BP STABLE. NSR. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS.\n\nRESP-O2 SAT 97% RA. LS CTA. NARD NOTED. C+DB ENC.\n\nGI-ABD SOFT/NT/ND. +BS. TOL PO'S. HAD BM TODAY. INCISION OTA, C/D/I. JP WITH SEROUSSANG DR.\n\nGU-FOLEY D/C'D. VOIDING SPONT VIA URINAL.\n\nACT-OOB TO CHAIR MOST OF DAY. TOL WELL.\n\nCOMFORT-DENIES NEED FOR PAIN MED.\n\nENDO-SSRI AND NPH.\n\nID-AFEB. ON IMMUNOSUPPRESSANTS AND ABX.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. TX TO FLOOR WHEN BED AVAIL.\n" } ]

[ { "category": "Echo", "chartdate": "2153-12-25 00:00:00.000", "description": "Report", "row_id": 92555, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. MV Repair\nHeight: (in) 67\nWeight (lb): 165\nBSA (m2): 1.87 m2\nBP (mm Hg): 141/80\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 15:21\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Low normal LVEF.\nNo resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mitral valve\nannuloplasty ring. Moderate (2+) MR.\n\nTRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. The end-diastolic PR velocity is increased c/w PA diastolic\nhypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe right atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Overall left ventricular\nsystolic function is low normal (LVEF 50-55%). There is no ventricular septal\ndefect. The right ventricular cavity is moderately dilated with mild global\nfree wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. The\nmitral valve leaflets are moderately thickened. A mitral valve annuloplasty\nring is present. Moderate (2+) mitral regurgitation is seen. Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. The end-diastolic pulmonic regurgitation velocity is increased\nsuggesting pulmonary artery diastolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Symmetric left ventricular hypertrophy with borderline systolic\nfunction. Dilated and hypokinetic right ventricle. Moderate mitral and\ntricuspid regurgitation. Moderate pulmonary hypertension.\n\nFindings discussed with Dr. at 1545 hours on the day of the study.\n\n\n" }, { "category": "ECG", "chartdate": "2153-12-22 00:00:00.000", "description": "Report", "row_id": 255367, "text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing of baseline artifact is no longer recorded. The ventricular\nresponse has increased. ST-T wave changes persist without diagnostic interim\nchange.\n\n" }, { "category": "ECG", "chartdate": "2153-12-19 00:00:00.000", "description": "Report", "row_id": 255368, "text": "Artifact is present. Atrial fibrillation with a rapid ventricular response.\nNon-specific ST-T wave changes. No previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2197-08-30 00:00:00.000", "description": "Report", "row_id": 308226, "text": "Sinus rhythm with PVCs with PACs.\nPoor R wave progression - probable normal variant\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2197-08-29 00:00:00.000", "description": "Report", "row_id": 308227, "text": "Sinus rhythm, atrial premature complex\nconsider left atrial abnormality\nProlonged QT interval\nLow limb lead voltage\nST-T wave abnormalities\nSince previous tracing, decreased voltage; ST-T wave abnormalities more marked\nClinical correlation is suggested\n\n" }, { "category": "Nursing/other", "chartdate": "2197-08-30 00:00:00.000", "description": "Report", "row_id": 1289105, "text": "Respiratory Care\nPt. admitted to unit from OR intubated. ABGs reveal respiratory acidosis with normal oxygenation. Vent changes made in attemps to correct Ph. RSBI attempted to pt. respiratory drive remains impaired with very minimal respiratory effort. Sx for small amounts thick white secretions. Plan is to wean pt. to extubation as tol.\n" }, { "category": "Nursing/other", "chartdate": "2197-08-30 00:00:00.000", "description": "Report", "row_id": 1289106, "text": "Condition Update\nPlease see carevue for specifics.\n\nPt admitted to the sicu from the OR approx 2300. Pt intubated and sedated on a ppf gtt. Anesthesiologist saw st changes on ECG. 12 lead EKG done. 5 mg lopressor given, 10 mg morphine sulfate given. NS infusing. Cardiac enzymes drawn. PT in NSR. No ectopy. NEO gtt + fluid boluses given throughout the noc to maintain map >65. Pt also received 2 units prbc's. CXR done. Off the ppf gtt, pt opens his eyes. MAE. Follows commands consistently. PERRL. RR increased on vent for acidosis. Pt currently on AC 50%/5 peep. rr 20. LS are CTA. Pt sxn'd for a moderate amt of thick, white secretions. IVF 1/2 NS infusing for hydration. Foley patent and draining adequate amts of clear urine. NGT clamped. Lumbar JP drain to bulb sxn and draining large amts of bloody drainage. Post op dressing on pt's back is clean and dry.\n\nPlan: continue with current plan of care per sicu/ NSURG teams. ? extubate this am. q 8 hour cardiac enzymes x 3. Pain mgmt. Monitor hemodynamic status.\n" }, { "category": "Nursing/other", "chartdate": "2197-09-01 00:00:00.000", "description": "Report", "row_id": 1289111, "text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA 3 and brisk. +EOM's. Answers questions appropriately. Follows commands. Initiates conversation. Tongue midline, Smile symmetrical no drift. MAE in bed. OOB to chair with 2 mod assist. Able to weight bear but has a slow unsteady shuffling gait. Denies numbness and tingling. No loss of sensation. Back dressing CDI and changed by MD.\n\nRESP: LS clear and diminished. Sat 99-100% on 3L.\n\nCARDIAC: Afebrile. HR 60-70's SR. SBP 88-151. +PP. P-boots on.\n\nGI: Abd soft +BS. Tol soft heart healthy diet. (Family to bring in his dentures this afternoon).\n\nGU: Foley intact draining qs clear yellow urine.\n\nINTEG: Back dressing intact. Skin CDI.\n\nPSYCH/SOCIAL: Pleasant and cooperative. Son and daughter-in-law visited in the late am.\n\nOTHER: c/o difficulty hearing since surgery. MD exam with otoscope.\n\nPLAN: Transfer to floor pending bed availability. Aggressive BM management, Encourage OOB to chair, Provide extra comfort.\n" }, { "category": "Nursing/other", "chartdate": "2197-08-31 00:00:00.000", "description": "Report", "row_id": 1289109, "text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt A&Ox3, MAE with L leg weakness and decreased sensation in BLE, follows all commands, PEERL. C/O mod-severe constant incisional pain, recieving percocet prn with pos effect.\n\n CV: Pt remains nsb-nsr, rare PVC's and rare PAC's noted. No tachy episodes. SBP down to 80's after recieving Lopressor po and later recieving Percocet. MAP remained 59-60 and BP would recover to low 100's when pt was woken up. No intervention made at that time, MD notified. BP resolved on own. Denies CP. Palp dp/pt bilat. Hct stable at 28.3. No S.C. heparin at this point.\n\n Resp: LS clear bilat and diminished at bases. Denies SOB. Maintaining o2 sat >96% on 3L n/c. Pt C&DB with instruction from RN. Non-productive cough noted.\n\n GI: ABD soft, NT, pos bs x4. Diet advanced to clears, pt with little desire to drink or eat. Fluid intake encouraged. No BM.\n\n GU: adequate amounts of clear urine via foley cath.\n\n Skin: Incision on back with original OR dsg intact. Small amount of sanguinous drainage noted at base of dsg, no further drainage noted. JP x1 draining mod amounts of sanguinous drainage.\n\n Pt OOB to chair with assist x2.\n\nPlan; continue with current plan of care, pt called out to step down pnd Neurosurg ok, pain management, encourage po intake, OOB, PT consult, pulm toileting, provide pt and family with emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2197-09-01 00:00:00.000", "description": "Report", "row_id": 1289110, "text": "condition update\nneuro: alert and oriented x's 3, appropriate, moves all extremities to command, reports sensation in all extremities, though some numbness in lower extremities (baseline). Prn percocet for pain with fair relief.\ncv: sb to nsr with some pac's, bp stable, slightly hypotensive while sleeping. Hct stable. Lopressor and lisinopril held d/t hr 50's, and hypotension during the day. (discussed with dr. ).\nresp: ls clear diminished, n.c. off , 02 sat 94-97%. Pt using i/s appropriately.\ngi: abd soft, +bs, no bm. Pt c/o of some gas pain which self resolved. tolerating sips of clears - taking water with pills without difficulty.\ngu: foley draining adequate amts. clear yellow urine.\nendo: ssri\nskin: dsg dry and intact, scant blood tinged, jp draining bloody drainage.\nplan: cont. pulmonary toileting, oob to chair, p.t., advance diet as tolerated, i/s, pain management transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2197-08-30 00:00:00.000", "description": "Report", "row_id": 1289107, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: SEDATED ON PROPOFOL THIS AM, PERRL, MAE TO COMMAND, HAND GRASPS EQUAL. STARTED ON FENT GTT FOR PAIN, INITIALLY AT 25 AND INCREASED TO 50 FOR PT COMFORT\nCV: TACHYCARDIC THIS AM REQUIRING LOPRESSOR 2.5MG IV X1 AND FLUID BOLUS OF 400CC LR. NEO GTT ON AND OFF, OFF SINCE 1130. HR NOW 60-80 NSR. CK AND ISOENYMES SENT AS ORDERED. PT TRANSFUSED WITH 6 UNITS PLTS FOR PLT COUNT OF 90, REPEAT 126. PT ALSO GIVEN 2 UNITS PC FOR HCT 26.\nRESP: PROPOFOL WEANED TO OFF, PT PLACED ON CPAP WITH 5 IPS, 0PEEP. PT THEN EXTUBATED AT 1630 AND PLACED ON OPEN FACE TENT AT 50%. BS CLEAR BUT DIMINSHED IN LEFT BASES. SATS 100%\nGI: NPO, ABD SOFT, BS ABSENT. ORAL GASTRIC TUBE DRAINING BILIOUS. D/C'D WHEN EXTUBATED\nGU: CLEAR YELLOW URINE IN GOOD AMTS. PT TO RECEIVE 10MG LASIX AFTER EACH UNIT OF BLOOD\nENDO: ON SLIDING SCALE INSULIN= SEE FLOW SHEET.\nSKIN: BACK DRESSING DRY AND INTACT. JP TO BULB SX DRAINING MOD AMTS SANGUINOUS DRAINAGE.\nA/P: CONT. TO MONITOR HEMODYNAMICS AND RESP PARAMETERS, ENCOURAGE PULM TOILET POST-EXTUBATION, RECHECK HCT AFTER BLOOD TRANSFUSIONS. CONT. TO MONITOR FOR BLEEDING., FENT GTT FOR PAIN= TITRATE TO PT COMFORT\n\n" }, { "category": "Nursing/other", "chartdate": "2197-08-31 00:00:00.000", "description": "Report", "row_id": 1289108, "text": "condition update\nneuro: dozing most of night, easily arousable, appropriate, oriented x's 3, mae to command, pupils equal and reacitve, has sensation in all extremities. Pt c/o of constant aching in lower back which he describes as tolerable, fentynal gtt currently at 25mcg/hr. Pt reports that he has had difficulty hearing in the past, but that it was worse yesterday after the surgery, and a little bit better today, but not back to normal. Sicu ho o/c was notified. Will cont. to monitor.\ncv: sinus, with increased pac's and rare pvc's noted. sicu ho aware and at bedside to evaluate, electrolytes draw - mag repleted and ekg obtained. Pac's less frequent after mag repletion. At approx 2100, pt had spontaneous very brief episode of tachycardia 130's, treated with 2.5 lopressor and resolved. Ekg then repeated. Pt had 2nd episode of tachycardia 120 at approx 4am, sicu ho notified, treated with 2.5 lopressor with effect, hr down to 80's. Pt also slightly hypotensive overnight, sbp 80's while sleeping- sicu ho aware. Bp improved to 120's this am without intervention. Hct stable at 29. K+ 3.6 treated with 40meq po this am.\nresp: ls clear diminished, o2 sat 94-99% on 3 liters n.c.\ngi: abd soft, nontender, +bs, no bm, colace given.\nendo: covered with ssri\nskin/incision: dsg intact, small dry blood stain noted - unchanged over night. JP drained approx 110cc's of sanguinous drainage overnight.\nPlan: continue to check hct, monitor jp ouput, monitor hr/bp, prn lopressor, pulmonary toileting.\n" } ]

[ { "category": "Radiology", "chartdate": "2133-07-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 964190, "text": " 3:07 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n Admitting Diagnosis: RULE OUT TUBERCULOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with lethargy and hypoxia\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AKSb WED 4:49 PM\n No acute pathology.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST\n\n HISTORY: 50-year-old man with lethargy and hypoxia, following reported ETOH\n intoxication.\n\n TECHNIQUE: Contiguous 5-mm axial tomographic sections were obtained from the\n skull base through the vertex and viewed in brain and bone window on the\n workstation. Several of the sections are degraded by motion artifact and are\n repeated.\n\n FINDINGS: There are no comparison studies on record. There is no evidence of\n significant soft tissue injury and no underlying skull fracture is identified.\n There may be a small osteoma involving the left paramedian occiput. The\n included portions of the paranasal sinuses and mastoid air cells, as well as\n the middle ear cavities are clear. There is no intra- or extra-axial\n hemorrhage. The midline structures are in the midline and the ventricles and\n cisterns are normal in size and in contour. A small, approximately 1.9 cm\n relatively hyperattenuating focus in the right superolateral aspect of the\n posterior fossa is identified on a single section (2:8) and likely represents\n partial volume averaging of the tentorium; no similar focus is identified\n elsewhere. The -white matter differentiation is maintained, throughout,\n without no evidence of cerebral edema.\n\n IMPRESSION: No acute intracranial abnormality.\n\n COMMENT: These findings were discussed with the clinician caring for the\n patient at the time of the examination.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2133-07-01 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 964122, "text": " 8:59 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ?PE\n Field of view: 36 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with hypoxia, cough, bloody sputum and afebrile\n REASON FOR THIS EXAMINATION:\n ?PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj WED 10:27 AM\n No PE. Emphysematous changes. Multifocal ground glass opacities with\n mediastinal lymphadenopathy, likely infectious etiology. Recommend repeat\n chest CT in weeks to confirm resolution and exclude underlying mass.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA of the chest with and without contrast.\n\n INDICATION: 50-year-old male with hypoxia, cough, bloody sputum. Assess for\n pulmonary embolism.\n\n COMPARISONS: None.\n\n TECHNIQUE: Non-contrast, low-dose MDCT axial images were acquired of the\n chest. Following administration of 90 cc of Optiray intravenous contrast,\n MDCT axial images were acquired from the thoracic inlet to the upper abdomen.\n Coronal, sagittal and oblique reformatted images were then obtained.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are no filling defects\n present within the pulmonary vasculature that are consistent with pulmonary\n embolism. Incidental note is made of an anomalous, left-sided pulmonary vein\n draining the left upper lobe. The heart and great vessels are otherwise\n unremarkable. There is no pericardial effusion. The pulmonary artery is\n prominent measuring 3.1 cm in diameter. There is an enlarged prevascular\n lymph node measuring 21 x 12 mm (3:31). There is an enlarged right hilar\n lymph node measuring 18 x 15 mm (3:40). There are several other smaller\n precarinal and subcarinal lymph nodes. There are no pathologic axillary lymph\n nodes. There are diffuse, patchy bilateral ground glass opacities within all\n lobes of the lung. There are higher density focal patchy areas of\n consolidation present within the left lower lobe. There are emphysematous\n changes, most prominent in the right upper lobe. There are no pleural\n effusions. No pulmonary nodules are identified. The airways are patent to the\n level of the segmental bronchi.\n\n Limited views of the upper abdomen are unremarkable.\n\n BONE WINDOWS: There are no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n\n 1. No pulmonary embolism.\n\n (Over)\n\n 8:59 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ?PE\n Field of view: 36 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Multifocal patchy areas of ground glass opacity and consolidation in the\n setting of mediastinal and right hilar lymphadenopathy. Infectious etiologies\n including bacterial, viral, and other atypical infections, in addition to\n tuberculosis (less likely) should be considered. Emphysematous changes most\n prominent at the right lung apex. Repeat examination in weeks is\n recommended to confirm resolution.\n\n Findings were posted to the ED dashboard.\n\n" }, { "category": "Radiology", "chartdate": "2133-07-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 964107, "text": " 7:35 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with decreasing sats and hemoptasis\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreasing O2 sats, hemoptysis.\n\n CHEST, TWO VIEWS: Comparison with , 1:25 a.m. Improvement in\n aeration, however, bibasilar diffuse opacities have appeared or are more\n prominent in the interim. Cardiac shadow is probably top normal in size.\n Hilar shadows difficult to evaluate due to overlying patchy opacities. No\n mediastinal widening. No pleural effusion or pneumothorax. Osseous\n structures are within normal limits.\n\n IMPRESSION: Rapidly developing bibasilar opacities may represent aspiration\n pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2133-07-01 00:00:00.000", "description": "Report", "row_id": 228282, "text": "Sinus rhythm. J point elevation with early repolarization in the anterior\nprecordial leads, probably no change. Compared to the previous tracing\nof no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2133-07-01 00:00:00.000", "description": "Report", "row_id": 228283, "text": "Sinus rhythm. Anterolateral ST segment changes are suggestive of ischemia. No\nprevious tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-07-02 00:00:00.000", "description": "Report", "row_id": 1479469, "text": "Transfer note\nPt. called out of ICU and bed avlb. on 11R. Pt. aware of transfer. Transfer note by RN on day shift and agreed with assessment. Note faxed and report given to RN. Transfer orders . Pt. transfered via wheelchair at .\n" }, { "category": "Nursing/other", "chartdate": "2133-07-01 00:00:00.000", "description": "Report", "row_id": 1479465, "text": "MICU NPN Admit Note:\n40y.o. male transferred to MICU/SICU from EW this evening for r/o TB, mask ventillation.\n\nPMH: Sleep apnea, HTN, ETOH\n\nAllergies: NKA\n\nPt is smoker and will let us know if he needs the patch while here in hopital. He states he drinks beer daily. His CIWA in 0 at present which will need to be checked Q4hr. Written for valium PRN.\n\nPt was found passed out on bench and brought to EW by Police. In EW he was thought to be intoxicated. ETOH level was 250, tylenol level 10. All other tox screeen negative. Pt continued to be somnolent throughout the day and did not wake easily. When awake he related a story of recent fevers, night sweats, persistent cough with bloody sputum. Pt was cultured and CXR showed bilateral ground glass opacities. He went for chest CT which was negative for PE. Pt was having periods of apnea with sat drop so he was put on mask ventillation. Mental status failed to clear and he was sent for head CT which was negative. He was transferred to MICU for mask ventillation and s/o TB. Access is difficult and pt has one peripheral IV in place in left hand. Team aware.\n\nNeuro: Awake and alert. C/O chest discomfort with coughing. MAE. Stood for weight as the bed scale is not accurate in that room. Able to order dinner and ate well.\n\nCV: BP 130-150/60. HR 100-110 sinus tach. IVF NDS at 150cc/hr infusing into left hand IV. Need new orders after one liter infused. Pt had two sets CPK enzymes negative in EW. Unable to draw labs upon arrival to MICU. Team aware and will get labs themselves.\n\nResp: Initially put on mask ventillation but switched to 2L N/C with sats 96%-98%. Lungs sound wheezy insp/exp. Rhonchi also throughout. Pt states he has sleep apnea history. Ordered for three sputums to be induced. RT to get first specimen in AM as pt had already eaten large meal tonight before orders written.\n\nGI: Tolerates diet without difficulty. Abdomen is obese with positive bowel sounds.\n\nGU: Voids in urinal.\n\nID: Pt with temp 99 axillary on arrival. Written for PO azithromycin 500mg PO Q24hr and IV ceftriaxone QD which has been started. Needs three sputums for AFB.\n\nSocial: Pt has Aunt, involved. He has no proxy.\n" }, { "category": "Nursing/other", "chartdate": "2133-07-02 00:00:00.000", "description": "Report", "row_id": 1479466, "text": "Resp: Pt rec'd on 2 lpm n/c. Ordered for induced sputum x3. Went to attempt this evening and pt was finishing his second meal. Will obtain 1st sample in am. Pt has hx of osa and placed on our cpap \"E\" settings with 2 lpm bleed. MDI's ordered, instruction given and administered with spacer. Pt performed with good effort and technique. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2133-07-02 00:00:00.000", "description": "Report", "row_id": 1479467, "text": "Nursing Note: 1900-0700 pt full code, NKDA.\n\nAirborne Precs for R/O TB\n\nNeuro: pt 3, sleeping intermittently overnight. and cooperative with care. c/o mild back pain. amubulated well to commode with supervision. CIWA scale 4-5, checking CIWA q4h.\n\nResp: on nasal bipap (2L 02) during night r/t sleep apnea. tolerating well, removed at 0300 for ambulation and pts request presently sats 95-100 on 2L NC. LS rhonchi bilaterally. expectorated sputum sample and sent to lab. due for inducted sputum sample today for AFB.\n\nCV: HR 85-110 sinus rhythm, no ectopy. NBP 130's/60's. afebrile, last temp 98.5. pt noted to be diaphoretic overnight. pos distal pulses. K repleated overnight.\n\nGU: voids in urinal, see careview for totals.\n\nGI: abdomen obese, pos bowel sounds, Lg brown BM overnight. tolerates diet well.\n\nIV: left hand 20g PIV WNL. no further IVF ordered by team. pt has history of difficult venous access.\n\nSkin: skin intact, no breakdown noted.\n\nPlan: continue to assess and monitor for pain, CIWA scale, resp status, hemodynamic status. cont to update pt with POC. assessment ongoing.\n" }, { "category": "Nursing/other", "chartdate": "2133-07-02 00:00:00.000", "description": "Report", "row_id": 1479468, "text": "NPN: Review of Systems\nNeuro: Alert/oriented. Calm and cooperative. Conversing w/ medical staff. C/O pain w/ coughing.\n\nResp: Breathing unlabored. Exp. wheezes bilaterally. decreased BS in bases. Congested cough. 3rd sputum sample to be obtained for AFB. First 2 pending. Sao2 on 2L NC=07%.\n\nCV: SR. No ectopy. MAP 90s. Palpable DP/PT pulses bilaterally.\n\nGI: Hearty appetite. No c/o nausea. BM overnight. None this shift.\n\nGU: Voiding clear yellow urine.\n\nID: Afebrile. Sputum, blood and urine cultures pending. Antibiotics as ordered.\n\nSkin: Intact.\n\nSocial: Pt has spoken to relative on phone.\n\nA: Pt's respiratory and hemodynamic status stable.\n\nP: Cont. resp. precautions until results of sputum sample are known to be (-). Antibiotics as ordered. Transfer to floor when room available. Monitor as ordered.\n" } ]

[ { "category": "Radiology", "chartdate": "2116-04-09 00:00:00.000", "description": "RENAL U.S.", "row_id": 864396, "text": " 2:56 PM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: r/o renal artery stenosis; fibromuscular dysplasia evalutaio\n Admitting Diagnosis: NECK MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with hx of recurrent carotid artery dissections\n REASON FOR THIS EXAMINATION:\n r/o renal artery stenosis; fibromuscular dysplasia evalutaion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION 41-year-old male with a history of recurrent carotid artery\n dissections. Rule out renal artery stenosis.\n\n COMPARISONS: No comparisons are available.\n\n RENAL ULTRASOUND: The right kidney measures 12.5 cm. The left kidney\n measures 12.8 cm. It has normal echogenicity. There are no focal masses,\n stones, or hydronephrosis.\n\n Doppler images of the kidney vessels demonstrate normal arterial waveforms in\n the kidney parenchyma with resistive indexes ranging from 0.5 to 0.65.\n\n IMPRESSION: Normal renal ultrasound. There is no downstream evidence of\n renal artery stenosis.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-04-08 00:00:00.000", "description": "Report", "row_id": 1361072, "text": "Nursing update: Update given to -rn on . Neuro checks q2-unchanged thus far. Heparin infusing @ 900u/hr-next ptt due at 2200. Explained that pt's wife wanting to stay in room. Pt going to semiprivate room at this time. Explanation given to patient r/t wife already left for the night. Pt transferred to F509 off tele-clarified w/neuromed resident Dr. that pt does not need tele.\n" }, { "category": "Nursing/other", "chartdate": "2116-04-08 00:00:00.000", "description": "Report", "row_id": 1361070, "text": "Nursing summary:\n\n41yo male admitted from ed w/chief complaint of left neck mass/pain. Pt found to have dissection of left ICA. Pt with history of Right ICA dissection w/ mca stroke in 99-treated wtih heparin/coumadin at that time, completed rehab, at home on asa. Pt with residual left-sided hemiparesis but does own adl's. Pt transferred to icu for frequent neuro checks. Vascular and neuro consulting.\n\nNeuro: neuro assessment unchanged. pupils , equal and brisk,Pt oriented, following commands,tongue midline, no defecits on right side. Left arm without fine motor skills. Weaker than l.leg.(no change from baseline) Does ambulate at home without assistance but has fallen before. Pt currently on bedrest-was ambulating in ED prior to admission. Pt has had left neck discomfort upon admission but did not want tylenol. Discomfort diminished overnoc. PT still on q1hour neuro checks. Pt had ct and mri-see ccc for results. Pt's dilantin level high-doses decreased.\n\nCVS: PT bp stable overnoc in SR, no ectopy noted. Heparin started in ed@. aPTT @ 02 subtherapeutic-increased to 850u/hour-next ptt due @1000. pivx1\n\nPUlm: WNL\nGI: pt on house diet. no bm overnoc.\nGU: pt voiding per urinal-pt has not voided since 2300. Voiding without difficutly in ed. NS infusing@100ml/hr for maintenance.\nSkin: wnl\n\nsocial: pt's wife at bedside upon admission. Tearful and wanted to stay at bedside overnoc. Visiting policy explained and wife given option to sleep on cot in waiting area. Wife decided to go home-has phoned x2 overnoc and updated.\n\nPlan: Continue neuro checks for now. Heparin @ 850u/hr-goal ptt 50-70-recheck @ 1000. Assess need for social work support for wife. ?c/o.\n" }, { "category": "Nursing/other", "chartdate": "2116-04-08 00:00:00.000", "description": "Report", "row_id": 1361071, "text": "NPN 7A-7P\nNeuro: Hx 41yo male w/ hx of rt. ICA stroke in , following a right ICA dissection, w/ resulting left sided hemiparesis. (also hx of seizures w/ last stroke thus on Dilantin) Now presenting after discovering a lump on the left side of his neck. Pt was shaving when he felt it, and could feel it pulsating, never noted it before. CT of head reviewed by vascular indicative of L ICA dissection w/ evidence of pseudoaneurysm and stenosis. Transferred to MICU for anticoag and frequent neuro checks. Currently r/o connective tissue problem. On gtt at 900 units/hr, last PTT at 16:00 54. Goal 50-70.\nPt 3, perrl, 3-4mm/bsk. Rt sided bilat extrem strength and movement normal. Left low extrem. can lift and hold, left upper no movement. Speech clear, follows commands, cooperative, pleasant.\nResp: LS cta on RA. no cough noted, no c/o sob.\nCV: Nsr 60-80s. sbp 90-130's. no ectopy noted. +pp. no edema noted. no c/o cp.\nGI: house diet. No BM. abd soft, non-tender, non-distended. +BS.\nGU: voiding adequate amounts,clear yellow. Urine tox screen sent.\nSkin: wnl\nSocial: wife at bedside today, has anxiety husband's condition and fears Pt going off to floor where he will be less frequently observed. Social work consulted. Pt and wife both concerned/frustrated as to why this is happening a second time.\nPlan: Cont w/ Q2/hr neuro checks. Cont titrating heparin gtt to goal therapeutic goal. Pt called out to 5, bed avail. awaiting nurse to take PT. transfer note written and hand delivered to 5\n" }, { "category": "Radiology", "chartdate": "2116-04-07 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 863999, "text": " 12:00 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA CAROTID/VERTEBRAL W&W/O CONTRAST; MR CONTRAST GADOLIN\n Reason: MRI/MRA of head/neck to assess mass at L carotid bifurcation\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with ? Pulsatile mass of L neck. Please compare to Duplex.\n REASON FOR THIS EXAMINATION:\n MRI/MRA of head/neck to assess mass at L carotid bifurcation.\n ______________________________________________________________________________\n WET READ: JCT TUE 3:41 AM\n no diffusion abnormalities to suggest an acute infarction. MRA unchanged from\n . Tortuous course of left internal carotid artery. No evidence of\n dissection. Soft tissue lesion not as well seen as on ultrasound.\n WET READ VERSION #1 JCT TUE 2:44 AM\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n MRI SCAN OF BRAIN:\n\n HISTORY: Pulsatile mass in the left neck. Please compare to duplex\n ultrasound.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted brain imaging was obtained.\n\n FINDINGS: There is re-demonstration of the large right middle cerebral artery\n chronic infarction, which exhibits extensive encephalomalacic changes. The\n identical finding was visible on the prior MRI scan of the brain, dated\n . Susceptibility within the infarct, representing\n hemorrhagic residuum is seen on both studies, and also is unchanged in extent.\n Wallerian degeneration involving the right cerebral peduncle, right half of\n the pons and right sided medullary pyramid is also re-demonstrated. The\n diffusion weighted images show no areas suggestive of acute brain ischemia.\n The principal vascular flow patterns are identified.\n\n MR ANGIOGRAPHY OF THE CIRCLE OF & ITS TRIBUTARIES:\n\n TECHNIQUE: 3 dimensional time of flight imaging with multiplanar\n reconstructions.\n\n FINDINGS: The major tributaries of the Circle of are patent. There is\n no significant interval change compared to the prior MR angiogram of .\n\n\n Gadolinium enhanced MR angiography of the neck arterial vasculature as well as\n 2D time of flight imaging was also performed.\n\n FINDINGS: The Gadolinium enhanced study raises the question of a mild\n stenosis of the origin of the left common carotid artery with a possible more\n longitudinally extensive stenosis involving the innominate artery. However,\n at least a portion of the innominate artery is also delineated on the 2\n dimensional reconstructions and this apparent stenosis is not as convincingly\n demonstrated. If this information may be of further clinical utility,\n (Over)\n\n 12:00 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA CAROTID/VERTEBRAL W&W/O CONTRAST; MR CONTRAST GADOLIN\n Reason: MRI/MRA of head/neck to assess mass at L carotid bifurcation\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n correlative CT angiography will be helpful in determining whether the finding\n is artifactual in etiology. Once again, the origin of the left internal\n carotid artery is quite tortuous, with a nearly horizontal orientation of its\n most proximal portion. This configuration, identical to that seen in \n likely accounts for the so-called \"pulsatile left neck mass.\" Within the\n limitations of this technology, there is no definite evidence for the presence\n of hemodynamically significant stenosis, although subsequent multiplanar\n reconstructions suggest some irregularity of the lumen of this proximal\n portion of the left internal carotid artery, including a possible tiny flap,\n which could represent a dissection. Please note that the initial non- contrast\n axial fat saturated sections are not interpretable due to the images\n saturating water, and not fat. To some extent, this compromises the ability\n to detect a carotid dissection. The axial post Gadolinium fat saturated\n images are of excellent technical quality and do not appear to show additional\n abnormalities.\n\n CONCLUSION: No sign for the presence of an extravascular mass within the neck\n to suggest the presence of a carotid body tumor. Question of luminal flap in\n proximal left internal carotid artery, which could represent a dissection.\n Please see above report for additional findings.\n\n\n The findings of this report, including its amendments were fully discussed\n with Dr. , ER attending physician, subsequently with \n , M.D., vascular surgery resident, this morning ().\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-04-06 00:00:00.000", "description": "CAROTID DUPLEX US", "row_id": 863995, "text": " 10:23 PM\n CAROTID DUPLEX US Clip # \n Reason: dissection?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with pulsatile left neck mass\n REASON FOR THIS EXAMINATION:\n dissection?\n ______________________________________________________________________________\n WET READ: JCT TUE 2:48 AM\n patent carotid artery. no evidence of dissection. soft tissue density adjacent\n to internal carotid at the bifurcation with possible arterial and venous flow.\n represent carotid body tumor or enlarged lymph node. Other possibility is\n a clotted pseudoaneurysm.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old man with pulsatile left neck mass.\n\n Examination over the left neck was performed. The common external and\n internal carotid arteries are patent without evidence of an intimal flap to\n suggest dissection. The internal carotid artery is quite tortuous,\n corresponding to the palpable pulsatile mass. Adjacent to the internal\n carotid near the bifurcation is a soft tissue density, which measures 12 x 9\n mm. There does appear to be an attachment to the internal carotid artery.\n Color views are suggestive of arterial and venous flow within this lesion.\n\n IMPRESSION: No evidence of dissection. Soft tissue density adjacent to the\n internal carotid artery may represent a carotid body tumor. Other\n possibilities include an enlarged lymph node or less likely internal carotid\n pseudoaneurysm.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-04-07 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 864039, "text": " 9:41 AM\n CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Neck mass and ? of carotid body tumor--eval for aneyrusm or\n Admitting Diagnosis: NECK MASS\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with\n REASON FOR THIS EXAMINATION:\n Neck mass and ? of carotid body tumor--eval for aneyrusm or dissection.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CT ANGIOGRAPHY OF THE NECK:\n\n HISTORY: Prior MR angiogram raised the question of stenoses involving the\n origin of the innominate and left common carotid arteries.\n\n TECHNIQUE: Bolus intravenously enhanced imaging of the great vessel origins\n and the neck arterial vasculature.\n\n FINDINGS: There is no obvious stenosis of the origins of the great vessels\n from the aortic arch. However, the present study suggests that there is an\n intraluminal flap within the proximal 2 cm of the left internal carotid\n artery. The configuration of the lesion would raise the question of a\n dissection, although atherosclerotic disease may have flap-like\n abnormalities as a component of the disease. There is no overt associated\n hemodynamically significant stenosis and no definite evidence for the presence\n of an extravascular lesion such as a carotid body tumor. Please note that the\n PACS system is currently unable to display this case and the review necessary\n for this report was accomplished by examination of the images on the scanner\n display itself.\n\n These findings were communicated in full by telephone to Dr. ,\n vascular surgical resident caring for the patient, today.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2169-01-28 00:00:00.000", "description": "Report", "row_id": 99856, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.\nWeight (lb): 150\nBP (mm Hg): 160/80\nHR (bpm): 147\nStatus: Inpatient\nDate/Time: at 11:28\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith <35% decrease during respiration (estimated RAP (indeterminate).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Moderately depressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Moderately dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm). The rhythm appears to be atrial fibrillation.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left atrium is normal in size. The right atrial pressure is indeterminate.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is probably mild to\nmoderately depressed (LVEF= 40-45 %), although rapid atrial fibrillation and\npoor image quality make assessment difficult. Tissue Doppler imaging suggests\nan increased left ventricular filling pressure (PCWP>18mmHg). Right\nventricular chamber size is normal. There is moderate global right ventricular\nfree wall hypokinesis. The ascending aorta is moderately dilated. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is\nseen. There is moderate pulmonary artery systolic hypertension.\nNo pericardial effusion is seen.\n\nIMPRESSION: Suboptimal image quality. Rapid atrial fibrillation makes\nassessment of ventricular function difficult, but probable mild to moderate\nleft ventricular systolic dysfunction (cannot exclude focal wall motion\nabnormality). Elevated left ventricular filling pressures. Moderate global\nright ventricular dysfunction. Moderate to severe pulmonary hypertension.\nModerate tricuspid regurgitation.\n\nRecommend repeat study when ventricular response is controlled.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2169-01-31 00:00:00.000", "description": "Report", "row_id": 1667374, "text": "MICU nursing progress note 7P-7A\nEvents - Pt more awake, screaming \"Help me\". BIPAP removed and placed on 4L NC. ABG 7.26/65/130. Nebs and NTSx for copious tenacious thick tan secretions. Afib ^^ 130s, occ 180s while off BIPAP. Decision to place back on BIPAP and medicated with ativan .25 mg. Pt slept about 4 hrs after that. Required 250cc NS bolus for NBP 70/29 which improved BP 80s-110s/20s-50s, HR Afib 90s-100s. Additional ativan .25mg given ar 5AM for same agitation d/t unable to tolerarte BIPAP.\n\nNeuro - Lethargic, knows she's in or hospital, follows commands. Moves UE, no movment noted in LE. Asking for a drink, very thirsty. C/o back pain, repositioned and medicated with tylenol PR with effect.\n\nResp - BIPAP removed for 4 hrs last night as above, then back on BIPAP 10/5, 60%. RR teens on BIPAP, 20s-30s on NC. Sats 95-100%. Lungs are coarse throughout. Was able to expectorate large amts thick tan secretions, also NTSx for copious secretions x 1. Pt needs ativan to tolerate BIPAP.\n\nCV - Afib 90s->130s with bursts to 180s occ. Lopressor given x 1 which had no effect on HR but caused a decrease in BP to 70s. No further lopressor has been given. BP 70s-110s/20s-70s. LUE and bil LE very edematous. DP dopplerable, toes are cool and cyanotic. Unalble to palpate left radial pulse. Heparin gtt @ 950U/hr, next PTT pending.\n\nGI - Abd soft, +BS. Inc small amt soft brown stool x 2. NPO.\n\nGU - UOP 60cc/hr->15cc, improved after fluid bolus.\n\nSocial - Pts daughter called last night for update.\n\nPlan - Heparin gtt, titrate gtt per algorythm. BIPAP as tolerated, caution with sedatives. Pt is DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2169-01-31 00:00:00.000", "description": "Report", "row_id": 1667375, "text": "respiratory care\npt remained off the vent tol well. see respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2169-01-31 00:00:00.000", "description": "Report", "row_id": 1667376, "text": "MICU Nurse Progress Note 0700-1900\nEvents: pt resp arrested ? mucous plus at 16:15, became agonal/ asystolic, suctioned, mask bag ventilation done, pt pulse/ spont resp returned. however pt remians unresponsive. Daughter , patient now , all meds d/c'd started on morphine gtt at 2mg/hr. remians on 35% humidified face tent for comfort. Pupils dialated, non reactive, HR 100-120's Sinus tach, b/p 90's-100's/ 31-50.\n\nPlan: titrate morphine gtt for comfort, support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2169-01-31 00:00:00.000", "description": "Report", "row_id": 1667377, "text": "MICU nursing progress note 2100\nPt unresponsive on MSO4 gtt 2 mg/hr. Expired at 20:15. Family called and notified of pts death.\n" }, { "category": "Nursing/other", "chartdate": "2169-01-30 00:00:00.000", "description": "Report", "row_id": 1667371, "text": "MICU Nurse Progress Note 1500-1900\npt is a 73 yo F, trans. to MICU from CCU (pt was a MICU boarder) new L neck mass w/ trachial deviation; new a-fib w/ rvr & hyotension; +PE and large L IJ SVC blood clot; PMH: Lung CA, s/p lobectomy and remissiion x 5 years; ? breast mass on past mammogram in '(pt refused tx and workup); COPD; depression/anxiety; and glaucoma. placed on BiPap mask ventilation upon arrival to MICU r/t ABG 7.26/75/49.\n\nROS:\nNeuro: lethargic, resp to pain stim, ; unable to follow commands; no purposeful movement at this time. pt has been anxious/ agitated in the past requiring ativan.\n\nResp: LS coarse throughout; on BiPap 60% 10/5, 02 sat 95-100% f/u ABG on bipap 7.29/65/130. team is aware. pt tol Bipap mask well at this time.\n\nCVS: remains in A-fib, HR 98-130, lopressor dose increased to 5mg IVP q4hrs. however 4pm dose held r/t b/p low in the 80's-90's/ 30's-40's w/ MAP 40's-50's. heparin gtt restarted prior to transfer as pt too unstable to go for biopsy.\n\nGI: abd soft nontender + BS x 4 quads, pt is NPO r/t lethargy/ BiPap, meds changed to IV.\n\nGU: foley cath patent draining clear yellow urine 120-240ml/hr (pt rec'd 10mg IV lasix prior to trans.)\n\nID: started on unasyn for new pleural effusions on CT. pt is afebrile.\n\nsocial: daughter was in to visit pt in CCU, no contact w/ family since transfer to MICU. ? family plan to change to CMO if results of biopsy show new CA.\n\n" }, { "category": "Nursing/other", "chartdate": "2169-01-30 00:00:00.000", "description": "Report", "row_id": 1667372, "text": "Respiratory Care Note\nPt started on NIV secondary to ABG 7.26/75/49/35/3. Pt is lethargic at this time. Pt placed on NIV settings as noted. BS are essentially clear, but mild upper airway congestion. There was some improvement on follow up ABG on NIV with a PaCO2 of 65 and a PaO2 of 130. Plan to continue NIV as tolerated - pt is a DNI/DNR.\n" }, { "category": "Nursing/other", "chartdate": "2169-01-31 00:00:00.000", "description": "Report", "row_id": 1667373, "text": "Resp Care Note, Pt placed on NIV overnight for worsening resp status.Given Atrovent neb with nt suction for copious amts thick yellow secretion.ABG attempted unable to obtain.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2169-01-29 00:00:00.000", "description": "Report", "row_id": 1667368, "text": "73 YR OLD ADMITTED C NECK MASS OBSTRUCTING SWALLOWING, FOR BIOPSY TOMORROW ,DC HEPARIN 6 AM .LUL RESECTION FOR LUNG CA 5 YRS AGO,REFUSED FOR BREAST MASS IN 02 .HAS COPD,2PPD SMOKER X 40YRS.ALSO CLOT L IJ ,SVC,AXILLARY ,BRACHIAL VEIN.NEW ONSET RAPID AFIB RX C ESMOLOL, NOW DIG AND LOPRESSER.\n\nAFIB 110 TO 130 C BP 80 TO 120 SYSTOLIC,FLUID BOLLUSES X 2 250 CC EA.HEPARIN TO 850 U FOR PTT 56 ,REPEAT PTT PENDING .RADIAL PULSES PALP, ALL OTHER PULSES BY DOPPLER .FEET COOL .\n\nSAT 97 6L NP.BS COARSE C/R BLOOD TINGED\n\nPT APPEARS TO SWALLOW PURREED AND SOFT FOOD BUT THEN COUGHS MOST OF IT UP .TAKING THICK LIQUIDS BUT COUGHS ON THOSE SOMETIMES AS WELL.MEDS CHANGED TO IV.SOFT BR NEG STOOL X 3.\n\nCYU VIA FOLEY 30 TO 50 CC HR\n\nOOB TO COMMODE AND CHAIR C ASSIST 2 .APPROPRIATE C FAMILY.FAMILY UPDATED BY ATTENDING\n\nPROBABLY RECURRENT CA C POOR PROGNOSIS BX TOMORROW ,DC HEPARIN 6AM\n\nSUPPORTIVE CARE FOR COMFORT\nREPEAT PTT.\nASP PRECAUTIONS\n\n" }, { "category": "Nursing/other", "chartdate": "2169-01-30 00:00:00.000", "description": "Report", "row_id": 1667369, "text": "Nursing Progress Note\n1900-0700\nNSCLC .. S/P LOBECTOMY/RADIATION/CHEMO\nCOPD ..NEW NECK MASS ..LEFT UPPER QUADRANT MASS..RAPID AFIB .. WITH NEW PE\n NPO FOR US GUIDED NECK BIOPSY ( THYROID )\nHEPARIN AT 850 U/HR OFF AT 0600.\nCV HR 110-150 RAPID AFIB\nSBP 70'S-100'S...500 CC NS GIVEN TIMES ONE ...IV LOPRESSOR HELD DUE TO HYPOTENTION.\n2 EPISODES OF SUDDEN ANXIETY ... \" I NEED TO GET OUT OF BED \" RESPONDING WELL TO ONE MG OF IV ATIVAN\nCOMPLAIN OF LOWER BACK PAIN..DR CALLED FOR PAIN MED ORDER. ONE MG OF MS04 GIVEN WITH RELIEF.\nTURNED Q3-4 HOURS\nOOB TO CARDIAC CHAIR TIMES 2 WITH ASSIST\nSMALL AMOUNT OF LOOSE STOOL.\n AWAIT INPUT FROM ONCOLOGY REGARDING PLAN OF CARE\n" }, { "category": "Nursing/other", "chartdate": "2169-01-30 00:00:00.000", "description": "Report", "row_id": 1667370, "text": "NPN 7P-7A:\n\nTHE PT IS A 73Y/O FEMALE WHO IS S/P LOBECTOMY W/ RADIATION AND CHEMO. SHE HAD A MAMMOGRAM IN , WHICH WAS + FOR A LUMP. SHE REFUSED TO GET WORK UP FOR CANCER AT THAT TIME.\n\nSHE WAS ADMIT TO W/ PROGRESSIVE DYSPNEA, AND A NEW AF.SHE HAD A CTA WHICH SHOWED SMALL SUBSEGMENTAL PE. SHE ALSO CLOT IN THE LEFT ARM, AND A MASS ON THE RIGH SIDE OF HER NECK. LESION FOUND IN HER ABD.\n\nCXR TODAY SHOW INCREASING LARGE LEFT PLEURAL EFFUSION. ABG'S 7.26/75/49/3/35. SHE WILL START ON BIPAP ASAP. LS COURSE BILAT. LASIX 10MG IV WAS GIVEN. 590ML OUT. SHE HAS TRACHEA IS DIAVATED DEVIATED TO THE RIGHT.\n\nCV: A FIB W/ HR UP 170'S. LOPRESSOR HAS CHANGED TO Q4HOURS.\n\nNEURO: SHE IS LETHARGIC AND CONFUSED. PUPILS ARE EQUAL AND REACTIVE TO LIGHT.\n\nPOC: WHEN SHE IS STABLE SHE WILL HAVE A U/S GUIDED BIOPSY FOR THE MASS. LOPRESSOR. WILL START IV ABX.\n" }, { "category": "Nursing/other", "chartdate": "2169-01-28 00:00:00.000", "description": "Report", "row_id": 1667361, "text": "ccu npn (micu border)\n\ns\" I just want to get out of this bed...get me out of the bed...I don't know what I want!\n\n73 yr old adm to ccu ( as micu border) w pmh copd, uses o2 @ home. was 2ppd smiker x40 yrs. quit .hx nsclc s/p resection. has been in remission x5 yrs. hx of anxiety and depression. adm with sob. presents with new mass on l side of neck. left arm swelling and bilat leg/ankle edema. pt had mass noted on mammogram in but refused all follow up screening and diagnostics.recent hx of fatigue and wt loss. presents w new onset a-fib. hr in ew 180. started on diltiazem gtt. ct shows segmental pe,paratracheal mass w deviation of trachea to the left. lymph-adenopathy. cxr shows ? pna /pleural efussions. no fevers . started on abx. on intiail adm to ccu refused foley and blood draws.\n\ncv: on initial exam pt's hr 130-135 a-fib with sbp 120-130. diltiazem gtt @ 10mg with little effect on hr. @ diltiazem gtt d/cd and esmolol gtt started. no bolus per order d/t copd. gtt started @ 50mcg/kg/min. fair responce in hr down to 110-120 w slight drop in bp. received 1000cc ns bolus,slow over 1-2/hr. pt has had poor appetite,poor skin turgor, dry mucous mem. stable on esmolol gtt. 2300 pt had drop in bp 80/45 map 50. md aware. pt asymptomatic. but hr ^ 120's. 500cc ns bolus given w drop in hr ,good responce in bp. 0200 dropped bp again w ^ hr 130. md aware. ns bolus 500cc given w again good responce in bp and hr. sbp now 90-100,map's 58-64. denies cp. ext cool. pedal pulses weak 2+ bilat.\n\nresp; o2 sats on 4l np 95-98%. slight sob w repositioning and assistence to side of bed. bs cl/diminsihed w exp wheezes noted. started on atrovent mdi's. c/r thick yellow secretions. wheezes resolved w use of inhalers. voice hoarse.\n\ngi: asp precautions in light of swallowing difficulties d/t neck mass. pt can not tolerate thin liq. chocks and gags. dr aware. pt given meds crushed in jello. thick consistency better tolerated by pt. abd soft, + bs last bm . c/o nausea x1 but no vomiting. zofran x1 w good effect.\n\nneuro; a/o x3. will follow commnads. initialy refusing blood draws,foley. became aggrevated during discussion of poc and code status wishes. several attempts made to get oob and go to the bath room. can't understand why she needs to wear o2 sat monitor,leads ,bp cuff etc. states she feels anxious. po ativan 1 mg with little effect. trazadone 50mg given w little effect. repeat dose with little effect. pt demanding to get up and into chair or commode. diffucult to keep in bed. wrapped up in leads and lines several times. states she is scared to be here,scared of what may be wrong with her. support given and pt allowed to verbalize. sleep deprived. pt demanding to sit in chair. assisted to chair w nurse @ bedside. ativan 1mg iv given. resting in short naps. con't on psych meds. pt will answer questiond appropriatly. has good short term memory and recall events from the past.\n\ngu: pt consented to foley and placed without difficulty. urin\n" }, { "category": "Nursing/other", "chartdate": "2169-01-28 00:00:00.000", "description": "Report", "row_id": 1667362, "text": "(Continued)\ne 30-40cc yellow no sed. noted. bun 19 creat 0.7 los + 3200cc\n\nskin: intact. l arm swelling noted. pffered to elevate on pillow but pt refused. radial pulse in l arl is weak 2+ palp. cap refill <3 digits cool. r ij site w old ooz, now stabilized. ft bilat edema noted. pulses 2+ palp.\n\nid; wbc 24.8 no temp. bld cult x2 via line completed. ua/c&s sent. needs sputum cult sent. con't on abx\n\nlabs: hct 33.4\n k+ 4.2\n mg 2.0\n tsh pending. am labs pending\n\nsocial: no inquieres overnoc. pt has daughter (lives in ) named . this is pt's hcp. has another daughter in new who will visit this week.\n\ndispo; full code\n\na/p: con't asp precautions. awaiting tsh result. heme/onc consult today. / bx mass of neck. further w/u given new breast/neck masses. con't to support pt. needs plan to address anxiety in light of new hospitalization and possible diagnosis. social service consult would be helpful.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2169-01-28 00:00:00.000", "description": "Report", "row_id": 1667363, "text": "CCU NPN 0700-1900\n\nS/O:\n73 y/o female w/ hx of Lung CA s/p resection and remission x5 yrs. COPD, ? Breast mass on past mammogram '(treatment/workup refused). Now w/ new left neck mass with trachial deviation, swollen LUE, SOB, and new onset AF w/ rvr & hypotension.\n\n\" How did I get to ?\"\n\nNeuro: Alert & oriented x3 this am w/ decline in MS throughout afternoon. OOB to chair this am, OOB to commode, & chair again this afternoon. 1 person assist. Oriented this afternoon.\nPt has difficulty speaking, confused at times. Anxiety x1, medicated w/ Ativan 1 mg w/ good effect.\n\nCV: HR 110-140 afib w/ RVR. BP SBP 90-100, Maps > 60. Esmolol d/c'd, PO lopressor started. Dig started per EP/Cardiology consult. HR down to 110 from 120-130's after lopressor. SBP dropped to 85 after lopressor, w/ map of 62.\nOn Hep gtt for subsegmental PE. Currently at 750units/hr for PTT of 107. Next ptt at 2200.\nUS done of LUE-> Complete thrombosis of left IJ w/ extension to L SVC, axillary & portion of Brachial vein (partial occ).\nTotal of 1500cc given in NS boluses. NS at 150cc/hr x1 liter.\nMag repleted this am.\n\nResp: LS decreased t/o, course productive cough for brown sputum.\nO2 sat read 72% on RA this am. O2 sat 80's on 4lnc, O2 increased to 5lnc, but increased lethargy noted. O2 decreased to 3.5l w/ increased alertness. O@ sat 100% on 3.5l-> decreased to 2lnc. + SOB w/ activity. ? new (tiny) nodules t/o lungs on CT scan.\n\nGI: Poor Po intake, Pt tolerates Thickened liquids w/o aspiration, soft solids tolerated. OB neg stool. + bs. + right upper quad tenderness. - n/v.\nGU: Poor u/o this am >30cc/hr. u/o increased to 75cc/hr x2 hrs in response to 1 liter NS bolus. creat 0.8\n\nID: afebrile, wbc 25.7, No IV abx.\nSkin: intact, Lue swollen.\nSocial: Dtr from in today () is HCP. Dtr from NJ will arrive late tonight and visit in AM. Pt's condition discussed w// family.\nHeme Onc consulted -> need further imaging of neck in addition to torso/abd. Will decide to needle or surgically biospy neck mass after imaging.\n\nA/P: 73 y/o female w/ new onset AF w/ rvr in setting of new left neck mass. PE & large left IJ-SVC blood clot. On hep gtt.\nCont hep gtt. AF rate control.\nHeme onc following, plan for further CT scan, bx plans\n\n\n" }, { "category": "Nursing/other", "chartdate": "2169-01-28 00:00:00.000", "description": "Report", "row_id": 1667364, "text": "ADDENDUM:\nPT OOB TO COMMODE O2 2LNC, + C/O SOB, O2 SAT 79-80. SAT INCREASED TO 95 AT REST.\nINCREASED O2 REQUIREMENTS W/ ACTIVITY.\n" }, { "category": "Nursing/other", "chartdate": "2169-01-28 00:00:00.000", "description": "Report", "row_id": 1667365, "text": "ADDENDUM:\nPT OOB TO COMMODE O2 2LNC, + C/O SOB, O2 SAT 79-80. SAT INCREASED TO 95 AT REST.\nINCREASED O2 REQUIREMENTS W/ ACTIVITY.\n" }, { "category": "Nursing/other", "chartdate": "2169-01-29 00:00:00.000", "description": "Report", "row_id": 1667366, "text": "ccu npn\n\ns:\" Do you think I can go home after all my tests?\"\n\n73 yr old adm to ccu (a micu border) w pmh copd, hx 2ppd x40yrs. quit . hx nsclc s/p resection lul,/rad/chem x5 yrs ago,depression/anxiety on psych meds,glaucoma, pt presented to w c/o sob,fatigue, wt loss. presents w new mass on l side of neck, left arm swelling from shoulder to fingers,bilat leg edema. pt had ? breast mass on mammogram ,but she refused all f/u and diagnostics. presented to ew new onset a-fib w hr 180.started on diltiazem gtt. d/cd than on esmolol . seen by cardiology. now on lopressor/dig. recent ct shows segmental pe,paratracheal mass w deviation of tracheal to the left. lymph-adenopathy. cxr showed new noduals/bilat pleural effusions and ? pna. u/s of lue showed complete thrombus of l IJ w extension to l svc,axillary, partial occlusion of brachial vein. seen by heme/onc on . needs further imaging of neck/torso/abd before bx of thyroid mass.\n\ncv: remains in a-fib w hr 100-120. con't on lopressor/ received dig dose 0.25mg iv @ 2300 per order. sbp 100-120 w map's 60-70. con't on heparin 750u/hr w therapeutic ptt. no c/p cp. adequate bp overnoc. received 1 liter ns @ 150cc/hr. 3+ pedal edema. pulses dp/pt bilat by doppler. bilat arms rad pulses 2+,ulnar by doppler. bilat ft cold. upper ext wrm to touch.\n\nresp: remains on 2l np (copd) gets sob w any activity. o2 ^ to 4l w activity. bs cl/diminished occassional exp wheezes. con't on atc atrovent mdi's. c&r thick yellow secretions. sputum cult from contaminated w oral flora. sats 96-99%, but drop when o2 off to 87%. rr 19-27\n\ngi: asp precautions. no thin liquids for this pt. only meds crushed in pudding,applesauce or jello. must take slow. abd soft w some tenderness llq. stolls x3 in small amt's loose,w order,brown guaic neg. stool sent for c-diff. npo after mn. micu team will place ngt in am. in light of difficulty swallowing (d/t mass) pt will be unable to tol po contrast. scheduled for ct this am of torso/neck/abd and ? head\n\ngu: foley draining cl yellow urine. u/o 30-60cc/hr los + 7 liters. scheduled to get mycomist pre and post ct scan.\n\nskin; intact\n\nneuro; periods of anxiety. alert/periods of dozing. oriented x . follows commnads. mae bed alarm activated as on occassion will try to get up. received ativan and trazodone @ hs w good effect. periods of denial,but pt is starting to ask more questions about poc. when oob to chair requieres 1 assist, weak on her ft. pupils equal/brisk. con't on psych meds. can verbalize needs. voice is hoarse ? laryngeal nerve comprssion.\n\nid: bld,urine,stool cult pending. afebrile wbc ^ 20's\n\nlabs: am pending\n\nivf: ns @ 150cc/hr completing. will start fluids approx 1 hr prior to ct scan.\n\nsocial: lives in in winter. has two daughters. daughter lives in and is hcp. daughter in , will be flying in today. aware of current testing and additional poc.\n\na/p: ct scan w contrast today. heme/onc, cardioglogy\n" }, { "category": "Nursing/other", "chartdate": "2169-01-29 00:00:00.000", "description": "Report", "row_id": 1667367, "text": "(Continued)\nfollowing. place ngt. give contrast. con't fluids follow sats. cautious w po's d/t neck mass. given imaging result, needle vs for bx of neck mass.\n\n\n" }, { "category": "ECG", "chartdate": "2169-01-27 00:00:00.000", "description": "Report", "row_id": 283001, "text": "Probable atrial fibrillation or atrial flutter with variable block. Diffuse\nST-T wave changes likely secondary to faster rate. Compared to the previous\ntracing of atrial fibrillation is new and ST segment changes are also a\nnew finding.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2150-04-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1004968, "text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with pneumonia, sepsis\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n COMPARISON: .\n\n INDICATION: Followup.\n\n FINDINGS: As compared to the previous radiograph, there are no major changes.\n Minimal cardiomegaly with no pleural effusions, no focal pulmonary opacity\n suggestive of pneumonia. Subtle interstitial fluid overload. Otherwise, no\n major radiographic changes.\n\n IMPRESSION: No relevant changes as compared to the previous examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-04-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1005216, "text": " 2:27 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate or other evidence of pneumonia\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n F with dementia, fever and lethargy being treated for C. diff +cough\n REASON FOR THIS EXAMINATION:\n r/o infiltrate or other evidence of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever and cough.\n\n PA and lateral upright chest radiographs compared to .\n\n The bibasal opacities are noted, most likely representing atelectasis. There\n is also increase in the left perihilar area compared to previous radiographs\n which might represent a focus of developing infection, although atelectasis\n might be included in differential diagnosis. There is no pleural effusion or\n pneumothorax. There is no evidence of failure.\n\n Findings were discussed with Dr. over the phone at the time of\n dictation.\n\n DL\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2150-04-05 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1004914, "text": " 5:34 PM\n PORTABLE ABDOMEN; -77 BY DIFFERENT PHYSICIAN # \n Reason: please repeat KUB as prior exam not able to identify bowel l\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypotension, ? C diff colitis.\n REASON FOR THIS EXAMINATION:\n please repeat KUB as prior exam not able to identify bowel loops due to motion\n ______________________________________________________________________________\n WET READ: DXAe SUN 7:11 PM\n No air fluid levels. No evidence of obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL RADIOGRAPH\n\n INDICATION: -year-old woman with hypotension and C. difficile colitis.\n\n COMPARISON: .\n\n FINDINGS: Single portable supine radiograph was obtained. Image quality is\n again somewhat limited by patient motion. Percutaneous gastrostomy tube is\n present in the left upper abdomen. Air is present within nondilated and\n relatively featureless bowel loops. Calcifications are present within the\n pelvis. There is diffuse demineralization of osseous structures and\n degenerative changes in the lower lumbar spine.\n\n IMPRESSION: Nonspecific bowel gas pattern.\n\n" }, { "category": "Radiology", "chartdate": "2150-04-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1004801, "text": " 9:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with h/o SAH last year, here w/ F/delta MS\n REASON FOR THIS EXAMINATION:\n eval bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FBr SAT 10:06 PM\n complete resultion of old bilateral subdural hematomas. no acute intracranial\n pathology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with history of subarachnoid hemorrhage last\n year and altered mental status.\n\n Comparison is made to the prior study of .\n\n TECHNIQUE: Axial MDCT images of the head were obtained with no IV contrast\n administration.\n\n FINDINGS: No edema, masses, mass effect, hemorrhage or infarction is noted.\n The previously noted chronic subdural hematomas/hygromas have completely\n resolved. The ventricles and sulci are prominent suggesting involutional\n changes. Diffuse periventricular white matter hypodensity is consistent with\n small vessel disease. The lacunar infarct of the right thalamus is unchanged.\n There is mild mucosal thickening of the right maxillary sinus. The remainder\n of the paranasal sinuses and mastoid air cells are clear. Diffuse\n calcification of the cavernosal portions of ICA and both vertebral arteries\n are noted.\n\n IMPRESSION:\n\n 1. No acute intracranial pathology including no hemorrhage.\n\n 2. Complete resolution of previously noted subdural collections.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2150-04-05 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1004821, "text": " 3:04 AM\n PORTABLE ABDOMEN Clip # \n Reason: free air, air-fluid levels, other abnormalities\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abdominal pain and hypotension\n REASON FOR THIS EXAMINATION:\n free air, air-fluid levels, other abnormalities\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN \n\n CLINICAL INFORMATION: Pain, hypotension.\n\n FINDINGS:\n\n Portable erect abdominal radiograph is obtained. A percutaneous gastrostomy\n tube is present. There is substantial motion on the radiograph. Scattered\n foci of air are identified, but it is difficult to ascertain whether these are\n air-fluid levels or within non-dilated small bowel segments.\n\n IMPRESSION:\n\n Equivocal examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-04-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1004803, "text": " 9:38 PM\n CHEST (PA & LAT) Clip # \n Reason: eval pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with F, cough\n REASON FOR THIS EXAMINATION:\n eval pna\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, AT 2136 HOURS.\n\n HISTORY: Fever and cough.\n\n COMPARISON: .\n\n FINDINGS: No consolidation or edema is evident. A tortuous aorta is again\n identified. The cardiac silhouette is within normal limits for size. No\n definite effusion or pneumothorax is evident. The bones are severely\n osteopenic with an exaggerated kyphosis in the midthoracic spine again\n evident. There is a chronic fracture deformity involving the proximal right\n humerus.\n\n IMPRESSION: Bony changes as above. No acute pulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-04-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1004854, "text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with urosepsis vs Cdiff colitis, s/p fluid resuscitation\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 08:41.\n\n COMPARISON STUDY: .\n\n CLINICAL INFORMATION: C. difficile colitis, status post fluid resuscitation.\n\n FINDINGS:\n\n There is hyperinflation of the lungs with prominent interstitial pattern.\n Aorta is tortuous. Heart is within normal limits. Fracture deformity of the\n right proximal humerus.\n\n IMPRESSION:\n\n No change since prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-04-07 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1005147, "text": " 8:06 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: r/o infiltrate, edema, other acute process\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n F with Alzheimers C diff with cough\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, edema, other acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cough.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Again, there are low lung volumes with atelectatic streaks at the bases. No\n evidence of acute focal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005319, "text": " 10:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for free air under diaphragm\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with C diff colitis\n REASON FOR THIS EXAMINATION:\n assess for free air under diaphragm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: C. diff colitis. Question free air.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: The cardiomediastinal silhouette is within normal\n limits. Linear bibasilar atelectasis persists. There is no focal\n consolidation, pneumothorax, or pleural effusion. A percutaneous gastrostomy\n tube as well as clips in the right upper quadrant are visualized. There is no\n evidence of free air underneath the hemidiaphragms.\n\n IMPRESSION: Linear bibasilar opacities likely representing atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-04-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005796, "text": " 3:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o CXR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abdominal pain,\n REASON FOR THIS EXAMINATION:\n r/o CXR\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST, .\n\n HISTORY: -year-old woman with abdominal pain.\n\n FINDINGS: Single bedside AP examination labeled \"semi-erect, 1530 hrs\" is\n compared with similar studies dated and . There is vague opacity\n projected over the lateral aspect of the right hemithorax with blunting of\n that CP angle, as before, likely representing layering pleural effusion; left\n pleural effusion is unchanged. Allowing for the low lung volumes, there is no\n change in heart size with some pulmonary vascular congestion and mild\n interstitial edema. There is patchy subsegmental atelectasis, but no focal\n consolidation. Again demonstrated are a gastrostomy tube in the upper\n abdomen, cholecystectomy clips, and diffuse osteopenia with stable vertebral\n compressions.\n\n IMPRESSION:\n 1. Low lung volumes with subsegmental atelectasis.\n 2. Small bilateral effusions, slightly more marked than on .\n\n" }, { "category": "Radiology", "chartdate": "2150-04-11 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1005797, "text": " 3:16 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o toxic megacolon\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abdominal pain,\n REASON FOR THIS EXAMINATION:\n r/o toxic megacolon\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE ABDOMEN, .\n\n HISTORY: -year-old woman with abdominal pain; rule out toxic megacolon.\n\n FINDINGS: Limited bedside AP examination labeled \"supine, 1530 hrs\" with the\n patient rotated to her right is compared with similar study dated ; the\n overall appearance is not much changed. The entire abdomen is relatively\n \"gasless\" with scant gas in relatively featureless bowel loops in the right\n abdomen; however, there is no definite evidence of fluid-filled loops. The\n accompanying semi-upright chest radiograph demonstrates no definite\n pneumoperitoneum. Again demonstrated is the distal portion of a gastrostomy\n tube in the upper central abdomen and cholecystectomy clips. There is\n profound diffuse osteopenia with chronic-appearing compressions of several\n thoracolumbar vertebrae, with no definite acute fracture identified.\n\n IMPRESSION: Relatively \"gasless\" abdomen, as on the studies, of\n indeterminate significance in this patient; bowel obstruction with\n fluid-filled loops cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2150-04-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005611, "text": " 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for pulmonary edema, other interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with dementia, c. diff colitis, wheezing on exam.\n REASON FOR THIS EXAMINATION:\n please assess for pulmonary edema, other interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dementia with wheezing.\n\n FINDINGS: In comparison with study of , there is again low lung volumes.\n Slightly more prominent atelectatic changes are seen at the right base with\n little change in the streaks at the left base. Blunting of the left\n costophrenic angle persists.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-04-05 00:00:00.000", "description": "Report", "row_id": 1654301, "text": "pt febrile all day c spike to 102.9 RESPONDED TO TYLENOL.T 98.3 AT 6PM.ON VANCO PO ,IV AND IV CEFIPINE .STOOL AND URINE CX SENT .\n\nSR TO ST NO ECT.BP 80 TO 140.SUPPOERTED C 2L RINGERS,1 LITER NS.PT 7 LITERS POS.K REPLEATED . SAT 90 TO 97 DEPENDING ON FEVER .ON FACE TENT .BS COARSE,COUGHING NOT RAISING .TAKEN OFF RESP PRECAUTIONS .\n\nHUO 50 TO 10 .\n\nMEDS VIA GTUBE.COPIOUS LIQUID STOOL VIA FLEXISEAL .LIDOCAINE,ALOE VESTA FOR SKIN CARE ON EXCORIATED BUTTOCKS .\n\nDAUGHTER .PT C HER ,ALTHOUGH VERY LETHARGIC .SCREAMS WHEN TOUUCHED FOR TX .DAUGHTER STATES PT CAN SWALLOW,BUT HAS TF AT NIGHT.\nC DIFF SEPSIS\n\nMONITOR RESPONSE TO FLUIDS\nSKIN CARE\nCHECK WITH HO WHEN TF CAN BE STARTED\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-04-06 00:00:00.000", "description": "Report", "row_id": 1654302, "text": "NURSING PROGRESS NOTE\nS:\nO:PT IS YOF, NH RESIDENT WHO PRESENTED TO THE ED W/ WORSENING CONFUSION. RECENT FEVER, +UA. ON LEVOQUIN . ON INCREASED CONFUSION, TEMP 101.8 TO . HX COLD OVER 2WKS.TREATED W/ 5L OF NS FOR BORDERLINE HYPOTENSION 90S, THEN 100. GIV VANCO/CEFTRIAX. CT NEG.\nHX OF ALZHEIMER DEMENTIA, DEPRESSION, HTN, DM2, H/O SUBDURAL HEMATOMAS, AND HYGROMA, NOW RESOLVED, H/O HUMERUS FX, ?PUL FIBROSIS, S/P G-TUBE PLACEMENT.\n\nNEURO:ANSWERS TO NAME, YES. OTHERWISE SPEECH GARBLED. PRIMARY LANGUAGE ?POLISH. MOVES UPPER EXTREMITIES, AND MOVE LEGS ON BED. DOES NOT FOLLOW ALL COMMANDS AND RESISTS CARE. YELLING OUT DURING CARE.\n\nCV:90- NO VEA. +MUR, ?AI. LOW DIASTOLIC PRESSURES IN 40S\nSYS 90-100. NS BOLUS 500CC X1 W/ GOOD EFFECT. K-PHOS REPLACEMENT, KCL REPLACEMENT. CALCIUM REPLACE. LABS PENDING.\n\nRESP:LS COARSE BS L>R NON PROD CONGESTED COUGH. SATS 92-100% ON 70%FACE TENT.\n\nID:T MAX102.8, BC X2 SENT. TYLENOL GIVEN. PT ON , VANCO. C-DIFF PENDING ON VANCO PER GTUBE.\n\nGI;ABD SOFT, +BS, G-TUBE HEALED, DSG CHGED. FLEXISEAL EXPELLED X2. NOT REPLACED. INC OF GR LIQ STOOL.\n\nGU:YELL URINE W/SED.\n\nSKIN;PERI ANAL AREA EXCORIATED. W/ RED STREAK ON COCCYX. LIDO AND ALOE VISTA APPLIED.\nENDO AS PER SS, NO COV.\n\nA/P:REMAIN FEBRILE, CONTINUE ANTIBIOTICS. DISCUSS NUTRITION DURING ROUNDS.SKIN CARE. TYLENOL FOR TEMP.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-04-06 00:00:00.000", "description": "Report", "row_id": 1654303, "text": "S:\"Take it out of my nose\".\n\nPMX:DMZ, HTN, DEMENTIA, SDH, PULM FIBROSIS s/p g tube placement.\n\nGI:abd soft , non tender, bs +, + loose liquid bm. Pt has g tube in place. speech and swallow eval determined pt is unsafe to eat by mouth at this time. Pt is tube feed dependent. tube feeds will be started once nutrition consults. C-Diff positve.\n\nCV:hr 90's-100 bp low 90's low diastolis 40's 1L lac ring 150cc/hr improving bp now 106/58. bp up to 140's when pt is moved or agitated.\n\nID:afebrile on vancomycin po and IV, cefepime.\n\nResp:ls coarse, o2 sats on room air 95% desats when she is aggitated.non productive congested cough.\n\nGU:yellow/ urin c sed 25cc/hr urin output.\n\nendo:ss insulin.\n\nskin:perianal area and coccyx reddened excoriated are washed several time today with soap and water and aloe vesta barrier cream applied. pt turned frequently.\n\nA: yo c early sepsis.\n\nP:monitor i&o's, skim care, start tube feeds once order is confirmed, frequent turning, NPO.\n\n" }, { "category": "Nursing/other", "chartdate": "2150-04-05 00:00:00.000", "description": "Report", "row_id": 1654299, "text": "Respiratory Care:\nNasal aspirate obtained and sent to lab.\n" }, { "category": "Nursing/other", "chartdate": "2150-04-05 00:00:00.000", "description": "Report", "row_id": 1654300, "text": "MICU BORDER\nS\nO:PT IS A YOF A RESIDENT OF .PT HAS A HX OF ALZHEIMER DEMENTIA, DEPRESSION, HTN, DM2, SUBDURAL HEMATOMAS AND HYGOMAS, NOW RESOLVED. HX/HUMERUS FRACTURE PULMONARY FIBROSIS ?S/P G-TUBE W/ A HX OF UTI, TX W/LEVOQUIN . INCREASE LETHARGY. COUGH AND COLD X2WKS. FEBRILE ON ADM TO CCU FROM ER\n\nNEURO; PUPILS EQUAL AND REACTIVE TO LIGHT AND BRISK. ANSWERS TO NAME, DOES NOT FOLLOW ALL COMMANDS.MOVEMENT PURPOSEFUL. MOVES UPPER EXTREMITIES.\n\nCV: MHR 90-100S SR TO ST, NO VEA. + SYS/ MUR, POSSIBLE AI. VERY LOW DIASTOLIC PRESSURES. SEE CAREVUE. THIS AM BP 93, LR BOLUS GIVEN PER DR. . DP PALP. 2 PIV #18.\n\nRESP:LS DIM, W/ FAINT COARSE BS AT BASES.SAT 96-97%. PLACED ON COOL MIST AEROSOL FACE TENT 35%. PT W/ CONGESTED COUGH NON PRODUCTIVE AT THIS TIME. PT PLACED ON DROPLET . THIS AM PT SWABBED FOR FLU. SKIN PINK W+D.\n\nGI:SOFT ROUNDED ABD W/ +BS. G-TUBE SITE WELL HEALED, SITE CLEANSE AND DST APPLIED. DIAPER REMOVED ON ARRIVE. PERIANAL AREA EXCORIATED. PT INCONTINENT OF LIQ STOOL. FLEXISEAL INSERTED.\n\nGU:YELL URINE W/ SEDIMENT.\n\nSKIN:PERIANAL AREA EXCORIATED. AREA WASHED AND ALOE VISTA BARRIER CREAM APPLIED.COCCYX W/ REDDENED AREA 4CM X 0.25CM. LEFT HEEL REDDENED AND DOES NOT BLANCH. HEELS ELEVATED OFF BED.\n\nENDO:AM GLUC 123, NO COV AS PER SS.\n\nSOC: FAMILY WERE NOT W/ PT. UNABLE TO OBTAIN ADEQUATE HISTORY.\n\nA/P:BP TRENDING IN LOW 90S, 1 LITER LR HUNG. REPLACE ELECTROLYTES. CONTINUE ANTIBIOTICS. SEND STOOL FOR C-DIFF. PT PLACED ON CONTACT \n\n" }, { "category": "ECG", "chartdate": "2150-04-06 00:00:00.000", "description": "Report", "row_id": 180554, "text": "Sinus rhythm\nEarly precordial QRS transition - is nonspecific\nOtherwise probably normal ECG\nSince previous tracing of , sinus tachycardia absent and ST-T wave\nchanges decreased\n\n" }, { "category": "ECG", "chartdate": "2150-04-05 00:00:00.000", "description": "Report", "row_id": 180555, "text": "Sinus tachycardia\nEarly precordial QRS transition\nModest ST-T wave changes\nFindings are nonspecific\nSince previous tracing of , ST-T wave changes decreased\n\n" }, { "category": "ECG", "chartdate": "2150-04-04 00:00:00.000", "description": "Report", "row_id": 180556, "text": "Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous\ntracing of rate has increased and ST-T wave changes are more\nprominent.\n\n" } ]

[ { "category": "Echo", "chartdate": "2114-06-05 00:00:00.000", "description": "Report", "row_id": 60699, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulm htn\nHeight: (in) 64\nWeight (lb): 180\nBSA (m2): 1.87 m2\nBP (mm Hg): 152/61\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 11:40\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Dilated RV cavity. Mild global RV free wall hypokinesis.\nAbnormal septal motion/position consistent with RV pressure/volume overload.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nSevere PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). The right ventricular\ncavity is dilated with mild global free wall hypokinesis. There is abnormal\nseptal motion/position consistent with right ventricular pressure/volume\noverload. The aortic valve leaflets are moderately thickened. There is mild\naortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\nrelaxation. The tricuspid valve leaflets are mildly thickened. There is severe\npulmonary artery systolic hypertension. There is a trivial/physiologic\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , the right\nventricle appears slightly larger and free wall motion appears similar to\nslightly more depressed. Estimated pulmonary artery systolic pressure is now\nhigher.\n\n\n" }, { "category": "ECG", "chartdate": "2114-06-04 00:00:00.000", "description": "Report", "row_id": 112626, "text": "Baseline artifact. Sinus rhythm. Low limb lead voltage. Anterior T wave\ninversions. Since the previous tracing of there may be no significant\nchange.\n\n" }, { "category": "Radiology", "chartdate": "2114-06-04 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1081480, "text": " 11:34 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE; interval change in ILD\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with pulm htn, ILD, hx sarcoidosis p/w acute on chronic\n dyspnea.\n REASON FOR THIS EXAMINATION:\n r/o PE; interval change in ILD\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb TUE 2:01 AM\n No PE, though evaluation of subsegmental vessels at left base is limited. New\n bilateral small effusions and compressive atalectasis with scattered thickened\n septal lines- ? edema, less likely changes related to sarcoid. D/W Dr. \n 2:00\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest CT .\n\n INDICATION: History of pulmonary hypertension, ILD, and sarcoidosis, with\n acute-on-chronic dyspnea.\n\n COMPARISON: .\n\n TECHNIQUE: Volumetric CT acquisition of the chest before and after IV\n contrast administration per non-gated chest pain CTA technique.\n\n CTA CHEST: There is no pulmonary embolism. Thoracic aorta is normal in\n caliber and contour throughout. There is no dissection. Mild calcification\n at the aortic valve is of uncertain hemodynamic significance. Atherosclerotic\n calcifications also noted at the aortic arch, and there is slight tortuosity\n of the descending aorta.\n\n Cardiomegaly is unchanged. Mildly enlarged main pulmonary artery is stable in\n size at 26 mm. There is a small right pleural effusion, and trace left\n pleural effusion, with moderate dependent bibasilar atelectasis. Small\n pericardial effusion is slightly increased since prior exam. Scattered\n mediastinal lymph nodes measure up to 8 mm in the precarinal region (3, 29),\n not significantly changed from prior exam.\n\n Post-operative change related to prior right lower lobe wedge resection is\n stable. Mild interlobular septal thickening in lung apices, new from previous\n exam, is due to borderline pulmonary edema. There are no other signs of heart\n failure. Areas of traction bronchiectasis in the right mid lung, and left lung\n base are not significantly changed.\n\n Contrast phase of study performed in expiratory phase, elicits\n tracheobronchomalacia. At the level of the thoracic inlet, indentation of the\n posterior wall of the trachea, and concentric decrease in caliber reduces\n cross sectional area from 247 mm2 to 130 mm2. Similar concentric narrowing\n (Over)\n\n 11:34 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE; interval change in ILD\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n extends inferiorly to the level of the carina, where the trachea is narrowed\n from 18 mm in AP dimension to 6 mm on expiratory phase. The most severe\n narrowing in the bronchus intermedius decreases bronchial diameter from 10 mm\n to 2 mm on expiratory phase imaging.\n\n This study is not specifically tailored for subdiaphragmatic evaluation,\n except to note unchanged right renal cystic lesion, and hepatic hypodensity\n too small to definitively characterize.\n\n There is no osseous lesion suspicious for malignancy. T7 vertebral body\n hemangioma is unchanged.\n\n IMPRESSION:\n\n 1. No pulmonary embolism.\n\n 2. Tracheobronchomalacia.\n\n 3. New, mild pulmonary edema, and small pleural effusions, right greater than\n left, responsible for bibasilar atelectasis.\n\n 4. Unchanged bibasilar bronchiectasis.\n\n 5. Unchanged mildly enlarged main pulmonary artery, and global cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2114-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081357, "text": " 10:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with ILD and SOB\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: at 15:44; CT, .\n\n SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: There is persistent cardiomegaly.\n Mediastinal and hilar contours are unchanged. The aorta is calcified and\n unfolded. There is bibasal atelectasis and likely small left effusion. There\n are rib fractures on the right associated with pleural thickening. Chain\n sutures are again seen in the right upper lobe. There is no pneumothorax.\n\n IMPRESSION: Bibasal atelectasis and likely small left effusion.\n\n\n" }, { "category": "Nursing", "chartdate": "2114-06-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577420, "text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Bibasilar crackles, pt appears to have labored breathing, closed face\n mask at 90% (15 liters),\n Action:\n Resp parameters monitored, lasix 40mg iv given, attempt to change to\n nasal cannula at 4 liters resulted in drop in sat to 84%\n Response:\n Excellent diuresis from lasix, currently on nasal cannula at 4 liters\n and closed face tent at 90% with sat 92%, pt states that her breathing\n is better\n Plan:\n Continue to wean O2 as tolerated, ? further diuresis\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Tolerating diet well, blood sugars 98-99\n Action:\n Blood sugars collected prior to meals\n Response:\n No sliding scale insulin required\n Plan:\n Continue to check blood sugars prior to meals and at bedtime and treat\n according to sliding scale\n" }, { "category": "Nursing", "chartdate": "2114-06-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577421, "text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Bibasilar crackles, pt appears to have labored breathing, closed face\n mask at 90% (15 liters),\n Action:\n Resp parameters monitored, lasix 40mg iv given, attempt to change to\n nasal cannula at 4 liters resulted in drop in sat to 84%\n Response:\n Excellent diuresis from lasix, currently on nasal cannula at 4 liters\n and closed face tent at 90% with sat 92%, pt states that her breathing\n is better\n Plan:\n Continue to wean O2 as tolerated, ? further diuresis\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Tolerating diet well, blood sugars 98-99\n Action:\n Blood sugars collected prior to meals\n Response:\n No sliding scale insulin required\n Plan:\n Continue to check blood sugars prior to meals and at bedtime and treat\n according to sliding scale\n" }, { "category": "Nursing", "chartdate": "2114-06-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577422, "text": "Chief Complaint: 79 year-old female with history of sarcoidosis,\n moderate pulmonary hypertension, ILD, and diabetes mellitus type 2 who\n presents with acute on chronic dyspnea\n 24 Hour Events:\n Chest CTA: No PE, though evaluation of subsegmental vessels at left\n base is limited. New bilateral small effusions and compressive\n atalectasis with scattered thickened septal lines- ? edema, less likely\n changes related to sarcoid. D/W Dr. 2:00\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Bibasilar crackles, pt appears to have labored breathing, closed face\n mask at 90% (15 liters),\n Action:\n Resp parameters monitored, lasix 40mg iv given, attempt to change to\n nasal cannula at 4 liters resulted in drop in sat to 84%\n Response:\n Excellent diuresis from lasix, currently on nasal cannula at 4 liters\n and closed face tent at 90% with sat 92%, pt states that her breathing\n is better\n Plan:\n Continue to wean O2 as tolerated, ? further diuresis\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Tolerating diet well, blood sugars 98-99\n Action:\n Blood sugars collected prior to meals\n Response:\n No sliding scale insulin required\n Plan:\n Continue to check blood sugars prior to meals and at bedtime and treat\n according to sliding scale\n" }, { "category": "Nursing", "chartdate": "2114-06-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577144, "text": ".H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt takes glypizide at home for tupe 2 diabetes\n Action:\n Pt on iv of Nss and able to have regular diet with carb control,\n sliding scale\n Response:\n Bs on admission to sicu 236-received 4 units Humalog via sliding scale\n Plan:\n Continue to monitor glucose levels and rx via sliding scale\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt has hx of pulmonary hypertension-has never smoked but second hand\n exposure\n Action:\n Pt on 100% NRB on admission, presently on 60% high-flow mask\n Response:\n 02 sat 95-96%, lungs clear, pt states sob resolved\n Plan:\n Continue with weaning 02 as able, encourage chest pt and deep\n breathing,\n" }, { "category": "Physician ", "chartdate": "2114-06-04 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 577188, "text": "TITLE:\n Chief Complaint: Primary Care Physician: , MD (APG)\n Primary Pulmonologist: , MD\n Chief Complaint: SOB\n HPI:\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea. She is followed by Dr. as an outpatient\n and was last seen by him on ; at that time, she was doing well,\n satting 95% on 4L at rest. Her recent history is notable for an\n admission at the end of where she presented with worsening\n dyspnea, ruled out for PE, and was transitioned from prednisone to\n sildenafil. She has seen Dr. in the interim and started on\n lasix for volume overload in the setting of right heart failure and\n prednisone-related fluid retention and weight gain. As noted above,\n she was been doing well, using a stable amount of supplemental oxygen\n at home and able to ambulate several feet with only mild dyspnea.\n Two days prior to admission, however, she noted worsening dyspnea with\n exertion. She also developed a nonproductive cough but denied sick\n contacts, fevers, chills, arthralgias, and chest pain. Her symptoms\n worsened and she called Dr. office on the day of admission\n and was advised to present to the ED.\n In the ED, initial vs were: 98.1 141/53 73 26 84%4L. She was placed on\n a NRB with 100% o2 sat and given solumedrol 125 mg IV x 1. A chest\n x-ray showed bilateral interstial infiltrates and she was admitted to\n the MICU for further management.\n On interview in the MICU, she was satting 96% on a high-flow mask\n (~10L) and breathing comfortably at a rate of 18.\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n chest pain or tightness, palpitations. Denied nausea, vomiting,\n diarrhea, constipation or abdominal pain. No recent change in bowel or\n bladder habits. No dysuria. Denied arthralgias or myalgias.\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Sildenafil 20 mg PO TID\n 2. Atenolol 100 mg PO QD\n 3. Lisinopril 40 mg PO BID\n 4. Nifedipine XL 120 mg PO BID\n 5. Simvastatin 80 mg PO QD\n 6. Acetaminophen mg PO Q6H PRN\n 7. MVI\n 8. Calcium Citrate + D 315-200 mg-unit tablets \n 9. Glipizide 7.5 mg PO QD\n 10. Lasix 40 mg PO QD\n Past medical history:\n Family history:\n Social History:\n # pulmonary artery HTN, on 2LPM continuous with exertion to maintain O2\n saturation > 88% (96% on 4L pulsed); RA sat as low as 76% w/ ambulation\n per Dr. in .\n # sarcoidosis with ILD, s/p right lower lobe resection in \n # hypertension\n # diabetes\n # renal insufficiency baseline creatinine 1.2-1.6\n # osteoarthritis\n # iron deficiency anemia\n # osteopenia\n # hyperlipidemia\n # colonic adenomas\n # s/p hysterectomy\n # s/p cataract surgery\n Her family history is notable for a mother who had a history of\n hypertension, diabetes, and coronary artery disease; a father with\n diabetes and coronary artery disease; and a brother also with\n hypertension, diabetes, and coronary artery disease. She denies any\n known history in her family of sarcoidosis or other lung diseases.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Denies present or past tobacco or alcohol use. Lives at home\n with her grandchild.\n Review of systems:\n Cardiovascular: no cp\n Respiratory: Dyspnea\n Flowsheet Data as of 08:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 81 (72 - 82) bpm\n BP: 169/70(94) {108/61(85) - 169/97(100)} mmHg\n RR: 19 (16 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,101 mL\n PO:\n 650 mL\n TF:\n IVF:\n 451 mL\n Blood products:\n Total out:\n 0 mL\n 225 mL\n Urine:\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 876 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 94%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar to mid-back)\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm, No rash\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A6/1/ 05:57 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TropT\n <0.01\n Other labs: CK / CKMB / Troponin-T:97//<0.01, ALT / AST:13/\n Imaging: CXR (): bilateral interstitial opacities, no focal\n infiltrate, bibasilar atelectasis, likely small left pleural effusion\n Echo ():\n The left atrium is mildly dilated. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n >55%). Right ventricular chamber size and free wall motion are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve appears structurally normal with trivial mitral regurgitation.\n There is moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion. Compared with the report of the prior study\n (images unavailable for review) of , there is now mild aortic\n regurgitation otherwise no significant change.\n IMPRESSION: Normal left and right ventricular function. Mild aortic\n regurgitation. Moderate pulmonary hypertension.\n CTA Chest ():\n 1. No signs of acute or chronic pulmonary embolism.\n 2. Unchanged nonspecific pulmonary fibrosis affecting the right lung to\n a greater degree than the left, possibly due to the provided diagnosis\n of sarcoid, but atypical for this entity.\n 3. Unchanged widespread ground-glass opacity and heterogeneous\n attenuation, possibly due to pulmonary hypertension.\n 4. Enlarged main pulmonary artery, right atrium and right ventricle\n consistent with proven pulmonary hypertension.\n 5. Bibasilar bronchiectasis.\n 6. Multiple renal lesions, evaluated by renal ultrasound on . Followup was recommended. Please refer to that report.\n 7. Smaller left apical nodule since the prior study, likely reactive.\n 8. Gallstones.\n 9. Liver and splenic hypodensities, too small to characterize. The\n larger liver hypodensity is unchanged since .\n Right heart cath :\n COMMENTS:\n 1. Resting hemodynamics revealed normal right sided filling pressures\n with a RVEDP of 8 mm Hg. There was moderate pulmonary hypertension with\n average PA pressure of 53/23 (mean 35) mm Hg, with peak phasic PASP to\n 60 mm Hg. Systemic arterial pressures were normal, measured\n noninvasively. The cardiac index and ouput were 2.0 L/min/m2 and 3.6\n L/min, respectively, using an assumed oxygen consumption of 125 mL\n O2/min/m2. The PVR was 4.4 Wood units. There was no evidence of\n significant right-left or left-right shunting at rest.\n 2. Hemodynamics following inhalation of 100% FIO2 for 15 minutes\n revealed average PA pressure of 60/21 (mean 35) mm Hg, with peak phasic\n PASP to 64 mm Hg, a cardiac index and ouput of 2.3 L/min/m2 and 4.1\n L/min respectively (using an assumed and unchanged oxygen consumption,\n although the patient was sleeping during part of the study), and a PVR\n of 4.4 Wood units.\n 3. Hemodynamics following inhalation of nitric oxide at 40 ppm plus\n 100% FIO2 for 15 minutes revealed an average PA pressure of 52/20 (mean\n 32) mm Hg with peak phasic PASP of 56 mm Hg, a cardiac index and output\n of 2.6 L/min/m2 and 4.7 L/min respectively (again using an assumed and\n unchanged oxygen consumption, although the patient was sleeping during\n part of the study), and a PVR of 3.2 Wood units.\n 4. Arterial access was not obtained.\n FINAL DIAGNOSIS:\n 1. Moderate-severe pulmonary artery hypertension.\n 2. Normal right ventricular diastolic function.\n 3. No evidence of significant right-to-left or left-to-right shunting\n at rest.\n 4. No significant improvement in PA pressures with 100% O2 or inhaled\n NO.\n ECG: NSR, nl axis, nl intervals, TWIs in V1-V4 (old except for V2), s\n wave in I, q wave in III, TWI in III (all old)\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n # Hypoxic respiratory failure: Her constellation of symptoms is most\n likely secondary to respiratory decompensation in the setting of a\n viral URI and poor respiratory reserve. Contributing factors to her\n poor respiratory function include known pulm hypertension and ILD,\n though it is unclear whether this is secondary to sarcoidosis or\n another etiology. Notably, her CXR appears more concerning when\n compared to prior imaging studies, as her interstitial changes are more\n marked, and this is concerning for progression of ILD. Arguing against\n progression of pulm htn is her overall improvement on sildenafil, as\n noted on her recent appointment with Dr. on . Other\n etiologies to consider include PE, pneumonia.\n - chest CTA to further characterize ILD, r/o PE\n - rapid respiratory viral screen\n - sputum cx\n - ECHO to assess PA pressures\n - hold off on solumedrol for now pending chest CT\n - empiric vanc/levo to cover for pna pending culture data\n - cont sildenafil\n - wean shovel mask as tolerated\n - no ABG given absence of respiratory distress or mental status changes\n - ROMI\n # Pulmonary hypertension/right heart failure: Underwent right heart\n cath in and had PA pressure of 53/23. PA htn of unclear\n etiology, possibly secondary to sarcoidosis though pattern on chest CT\n not typical for this disease. Now appears to have more profound lung\n disease on chest x-ray, but was doing well in clinic one week prior to\n admission so unlikely to have sildenafil treatment failure.\n - cont sildenafil\n - cont lasix with caution given preload dependence of right ventricle\n - ECHO as above\n # Hypertension: Stable.\n - cont ACEi, CCB, beta blocker\n # Diabetes mellitus type II: Stable.\n - hold oral hypoglycemics\n - ISS\n # Chronic renal insufficiency: Creatinine at baseline of 1.5.\n - mucomyst and IVFs prior to CTA\n - renally dose meds\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 PM\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2114-06-04 00:00:00.000", "description": "Resident / Attending Admit Notes", "row_id": 577189, "text": "TITLE:\n Chief Complaint: Primary Care Physician: , MD (APG)\n Primary Pulmonologist: , MD\n Chief Complaint: SOB\n HPI:\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea. She is followed by Dr. as an outpatient\n and was last seen by him on ; at that time, she was doing well,\n satting 95% on 4L at rest. Her recent history is notable for an\n admission at the end of where she presented with worsening\n dyspnea, ruled out for PE, and was transitioned from prednisone to\n sildenafil. She has seen Dr. in the interim and started on\n lasix for volume overload in the setting of right heart failure and\n prednisone-related fluid retention and weight gain. As noted above,\n she was been doing well, using a stable amount of supplemental oxygen\n at home and able to ambulate several feet with only mild dyspnea.\n Two days prior to admission, however, she noted worsening dyspnea with\n exertion. She also developed a nonproductive cough but denied sick\n contacts, fevers, chills, arthralgias, and chest pain. Her symptoms\n worsened and she called Dr. office on the day of admission\n and was advised to present to the ED.\n In the ED, initial vs were: 98.1 141/53 73 26 84%4L. She was placed on\n a NRB with 100% o2 sat and given solumedrol 125 mg IV x 1. A chest\n x-ray showed bilateral interstial infiltrates and she was admitted to\n the MICU for further management.\n On interview in the MICU, she was satting 96% on a high-flow mask\n (~10L) and breathing comfortably at a rate of 18.\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n chest pain or tightness, palpitations. Denied nausea, vomiting,\n diarrhea, constipation or abdominal pain. No recent change in bowel or\n bladder habits. No dysuria. Denied arthralgias or myalgias.\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Sildenafil 20 mg PO TID\n 2. Atenolol 100 mg PO QD\n 3. Lisinopril 40 mg PO BID\n 4. Nifedipine XL 120 mg PO BID\n 5. Simvastatin 80 mg PO QD\n 6. Acetaminophen mg PO Q6H PRN\n 7. MVI\n 8. Calcium Citrate + D 315-200 mg-unit tablets \n 9. Glipizide 7.5 mg PO QD\n 10. Lasix 40 mg PO QD\n Past medical history:\n Family history:\n Social History:\n # pulmonary artery HTN, on 2LPM continuous with exertion to maintain O2\n saturation > 88% (96% on 4L pulsed); RA sat as low as 76% w/ ambulation\n per Dr. in .\n # sarcoidosis with ILD, s/p right lower lobe resection in \n # hypertension\n # diabetes\n # renal insufficiency baseline creatinine 1.2-1.6\n # osteoarthritis\n # iron deficiency anemia\n # osteopenia\n # hyperlipidemia\n # colonic adenomas\n # s/p hysterectomy\n # s/p cataract surgery\n Her family history is notable for a mother who had a history of\n hypertension, diabetes, and coronary artery disease; a father with\n diabetes and coronary artery disease; and a brother also with\n hypertension, diabetes, and coronary artery disease. She denies any\n known history in her family of sarcoidosis or other lung diseases.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Denies present or past tobacco or alcohol use. Lives at home\n with her grandchild.\n Review of systems:\n Cardiovascular: no cp\n Respiratory: Dyspnea\n Flowsheet Data as of 08:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.5\n HR: 81 (72 - 82) bpm\n BP: 169/70(94) {108/61(85) - 169/97(100)} mmHg\n RR: 19 (16 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,101 mL\n PO:\n 650 mL\n TF:\n IVF:\n 451 mL\n Blood products:\n Total out:\n 0 mL\n 225 mL\n Urine:\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 876 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 94%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar to mid-back)\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm, No rash\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A6/1/ 05:57 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TropT\n <0.01\n Other labs: CK / CKMB / Troponin-T:97//<0.01, ALT / AST:13/\n Imaging: CXR (): bilateral interstitial opacities, no focal\n infiltrate, bibasilar atelectasis, likely small left pleural effusion\n Echo ():\n The left atrium is mildly dilated. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n >55%). Right ventricular chamber size and free wall motion are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Mild (1+) aortic regurgitation is seen. The mitral\n valve appears structurally normal with trivial mitral regurgitation.\n There is moderate pulmonary artery systolic hypertension. There is no\n pericardial effusion. Compared with the report of the prior study\n (images unavailable for review) of , there is now mild aortic\n regurgitation otherwise no significant change.\n IMPRESSION: Normal left and right ventricular function. Mild aortic\n regurgitation. Moderate pulmonary hypertension.\n CTA Chest ():\n 1. No signs of acute or chronic pulmonary embolism.\n 2. Unchanged nonspecific pulmonary fibrosis affecting the right lung to\n a greater degree than the left, possibly due to the provided diagnosis\n of sarcoid, but atypical for this entity.\n 3. Unchanged widespread ground-glass opacity and heterogeneous\n attenuation, possibly due to pulmonary hypertension.\n 4. Enlarged main pulmonary artery, right atrium and right ventricle\n consistent with proven pulmonary hypertension.\n 5. Bibasilar bronchiectasis.\n 6. Multiple renal lesions, evaluated by renal ultrasound on . Followup was recommended. Please refer to that report.\n 7. Smaller left apical nodule since the prior study, likely reactive.\n 8. Gallstones.\n 9. Liver and splenic hypodensities, too small to characterize. The\n larger liver hypodensity is unchanged since .\n Right heart cath :\n COMMENTS:\n 1. Resting hemodynamics revealed normal right sided filling pressures\n with a RVEDP of 8 mm Hg. There was moderate pulmonary hypertension with\n average PA pressure of 53/23 (mean 35) mm Hg, with peak phasic PASP to\n 60 mm Hg. Systemic arterial pressures were normal, measured\n noninvasively. The cardiac index and ouput were 2.0 L/min/m2 and 3.6\n L/min, respectively, using an assumed oxygen consumption of 125 mL\n O2/min/m2. The PVR was 4.4 Wood units. There was no evidence of\n significant right-left or left-right shunting at rest.\n 2. Hemodynamics following inhalation of 100% FIO2 for 15 minutes\n revealed average PA pressure of 60/21 (mean 35) mm Hg, with peak phasic\n PASP to 64 mm Hg, a cardiac index and ouput of 2.3 L/min/m2 and 4.1\n L/min respectively (using an assumed and unchanged oxygen consumption,\n although the patient was sleeping during part of the study), and a PVR\n of 4.4 Wood units.\n 3. Hemodynamics following inhalation of nitric oxide at 40 ppm plus\n 100% FIO2 for 15 minutes revealed an average PA pressure of 52/20 (mean\n 32) mm Hg with peak phasic PASP of 56 mm Hg, a cardiac index and output\n of 2.6 L/min/m2 and 4.7 L/min respectively (again using an assumed and\n unchanged oxygen consumption, although the patient was sleeping during\n part of the study), and a PVR of 3.2 Wood units.\n 4. Arterial access was not obtained.\n FINAL DIAGNOSIS:\n 1. Moderate-severe pulmonary artery hypertension.\n 2. Normal right ventricular diastolic function.\n 3. No evidence of significant right-to-left or left-to-right shunting\n at rest.\n 4. No significant improvement in PA pressures with 100% O2 or inhaled\n NO.\n ECG: NSR, nl axis, nl intervals, TWIs in V1-V4 (old except for V2), s\n wave in I, q wave in III, TWI in III (all old)\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n # Hypoxic respiratory failure: Her constellation of symptoms is most\n likely secondary to respiratory decompensation in the setting of a\n viral URI and poor respiratory reserve. Contributing factors to her\n poor respiratory function include known pulm hypertension and ILD,\n though it is unclear whether this is secondary to sarcoidosis or\n another etiology. Notably, her CXR appears more concerning when\n compared to prior imaging studies, as her interstitial changes are more\n marked, and this is concerning for progression of ILD. Arguing against\n progression of pulm htn is her overall improvement on sildenafil, as\n noted on her recent appointment with Dr. on . Other\n etiologies to consider include PE, pneumonia.\n - chest CTA to further characterize ILD, r/o PE\n - rapid respiratory viral screen\n - sputum cx\n - ECHO to assess PA pressures\n - hold off on solumedrol for now pending chest CT\n - empiric vanc/levo to cover for pna pending culture data\n - cont sildenafil\n - wean shovel mask as tolerated\n - no ABG given absence of respiratory distress or mental status changes\n - ROMI\n # Pulmonary hypertension/right heart failure: Underwent right heart\n cath in and had PA pressure of 53/23. PA htn of unclear\n etiology, possibly secondary to sarcoidosis though pattern on chest CT\n not typical for this disease. Now appears to have more profound lung\n disease on chest x-ray, but was doing well in clinic one week prior to\n admission so unlikely to have sildenafil treatment failure.\n - cont sildenafil\n - cont lasix with caution given preload dependence of right ventricle\n - ECHO as above\n # Hypertension: Stable.\n - cont ACEi, CCB, beta blocker\n # Diabetes mellitus type II: Stable.\n - hold oral hypoglycemics\n - ISS\n # Chronic renal insufficiency: Creatinine at baseline of 1.5.\n - mucomyst and IVFs prior to CTA\n - renally dose meds\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 PM\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n CRITICAL CARE STAFF\n CC: respiratory distress\n I saw and examined the patient with the ICU team; Dr. \ns note\n reflects my input. I would add/emphasize that this 79-year-old woman\n with pulmonary hypertension and interstitial lung disease (on home O2)\n presents with dyspnea worsening since Friday. She noticed both URI\n symptoms (but no clear fever) and bilateral pedal edema. She had\n slightly worse orthopnea compared to normal. She denies changes in her\n environment (e.g pets) and has no definite sick contacts. She was\n hypoxemic in the ED, requiring NRB. Currently, she says she feels much\n better than on arrival to .\n PMH, Meds, SH, FH, and Allergies reviewed above. I would emphasize\n that her sarcoidosis seems quite remote, and that other ILDs are under\n consideration. In addition, a right heart cath showed\n resting hemodynamics as follows:\n RA: 9/8/6\n RV: 60/8\n PA: 53/23/35\n PCWP: 18/24/19\n CO/CI: 3.6/2.0\n PVR: 356\n Although PA pressures did not significantly change with O2 or NO,\n cardiac output/index did increase to 4.7/2.6.\n On examination she is comfortable. 94% on 60% high-flow, RR 19. Other\n VS as per metavision. Her neck veins are 10 cm. Heart is regular\n without gallops. There is a holosystolic murmur along the sternal\n border. I do not hear a diastolic murmur though she has documented\n AI. She has good air movement and some basilar crackles. Her abdomen\n is soft. There is trace edema peripherally.\n Labs are reviewed, notable for\n 147\n [image004.gif]\n 110\n [image004.gif]\n 13\n [image006.gif]\n 208\n [image007.gif]\n 3.6\n [image004.gif]\n 24\n [image004.gif]\n 1.5\n [image009.gif]\n WBC 8.1, no bands, Hct 36\n EKG reviewed; similar to \n CXR: increased basilar opacity bilaterally with loss of diaphragmatic\n shadow. Slightly larger cardiac silhouette but likely technique.\n Slightly larger azygous shadow. C/W .\n Assessment and Plan\n 79-year-old woman with respiratory distress on a background history of\n pulmonary hypertension (on sildenafil) and interstitial lung disease\n (hx of sarcoid, but currently other ILDs are under consideration;\n currently off prednisone for months).\n The etiology of her acute decompensation is not clear at present:\n the history for an infectious prodrome is certainly not\n overwhelming, though there is substantial community acquisition of\n viral disease (novel H1N1) at present and elderly patients with\n bacterial PNA may present atypically\n pulmonary embolism is not excluded and, given her limited\n reserve, even a small PE could create substantial problems with \n matching.\n she could also have acceleration of her underlying ILD,\n although there are not clear triggers and this seems less likely.\n finally, pulmonary edema from left heart (diastolic) failure\n could certainly play a role. Given that her mean PCWP on cath was 19\n (while corresponding RVEDP was 8), she certainly has substantial\n diastolic dysfunction.\n Although acute-on-chronic diastolic left heart failure may be quite\n likely, there are other potentially life-threatening diseases that\n warrant evaluation in the acute setting:\n 1) PE-protocol CT\n 2) Viral panel (including influenza DFA). Maintain\n droplet/contact precautions until DFA(-). Pretest probability is low\n enough that I would test but not treat at this current juncture.\n 3) Sputum culture. Antibiotics for CAP until CT is back and gram\n stain returns. If there is another diagnosis apparent, would move to\n discontinue antibiotics soon since pretest probability for bacterial\n infection is low.\n 4) If no diagnosis from above\n echo in the morning to eval\n changes in LV function, PA pressures, and valves.\n 5) even though she may be volume overloaded, will run\n comparatively wet overnight (and give NAC), given dye load from CT and\n mild CKD. Check proBNP for now (though elevated at baseline, low or\n very high values would be helpful)\n 6) If above evaluation is reassuring, would consider trial of\n treatment for diastolic CHF.\n Other issues as per ICU team note. Discussed with patient, daughter,\n and son.\n Critically ill: 45 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 21:13 ------\n" }, { "category": "Nursing", "chartdate": "2114-06-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577716, "text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n On 95% high flow neb w/ additional 5L NC. Sats 92-97%\n LS clear w/ crackles at the bases.\n Family at bedside\n Action:\n Lasix changed to IV.\n Pt desats quickly while eating to low 80\ns. Unable to titrate O2.\n Swan placed at 1800 by MICU attending for hemodynamic\n monitoring.\n Response:\n Sats remain 88-90 while asleep, 90-92 when awake.\n Tol procedure well. Cxray confirmed placement.\n Plan:\n OOB to chair in am.\n Monitor sats closely, Lasix as ordered.\n Hemodynamics Q12 as ordered.\n Emotional support provided to pt and family.\n" }, { "category": "Physician ", "chartdate": "2114-06-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577343, "text": "TITLE:\n Chief Complaint: 79 year-old female with history of sarcoidosis,\n moderate pulmonary hypertension, ILD, and diabetes mellitus type 2 who\n presents with acute on chronic dyspnea\n 24 Hour Events:\n Chest CTA: No PE, though evaluation of subsegmental vessels at left\n base is limited. New bilateral small effusions and compressive\n atalectasis with scattered thickened septal lines- ? edema, less likely\n changes related to sarcoid. D/W Dr. 2:00\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.7\n HR: 62 (62 - 89) bpm\n BP: 128/61(79) {106/48(62) - 169/118(122)} mmHg\n RR: 13 (13 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n Total In:\n 1,948 mL\n 639 mL\n PO:\n 740 mL\n 60 mL\n TF:\n IVF:\n 1,208 mL\n 579 mL\n Blood products:\n Total out:\n 625 mL\n 550 mL\n Urine:\n 625 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,323 mL\n 89 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 93%\n ABG: ////\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 228 K/uL\n 9.8 g/dL\n 29.1 %\n 10.6 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n WBC\n 10.6\n Hct\n 29.1\n Plt\n 228\n TropT\n <0.01\n Other labs: CK / CKMB / Troponin-T:97//<0.01, ALT / AST:13/\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n # Hypoxic respiratory failure: Her constellation of symptoms is most\n likely secondary to respiratory decompensation in the setting of a\n viral URI and poor respiratory reserve. Contributing factors to her\n poor respiratory function include known pulm hypertension and ILD,\n though it is unclear whether this is secondary to sarcoidosis or\n another etiology. Notably, her CXR appears more concerning when\n compared to prior imaging studies, as her interstitial changes are more\n marked, and this is concerning for progression of ILD. Arguing against\n progression of pulm htn is her overall improvement on sildenafil, as\n noted on her recent appointment with Dr. on . Other\n etiologies to consider include PE, pneumonia.\n - chest CTA to further characterize ILD, r/o PE\n - rapid respiratory viral screen\n - sputum cx\n - ECHO to assess PA pressures\n - hold off on solumedrol for now pending chest CT\n - empiric vanc/levo to cover for pna pending culture data\n - cont sildenafil\n - wean shovel mask as tolerated\n - no ABG given absence of respiratory distress or mental status changes\n - ROMI\n # Pulmonary hypertension/right heart failure: Underwent right heart\n cath in and had PA pressure of 53/23. PA htn of unclear\n etiology, possibly secondary to sarcoidosis though pattern on chest CT\n not typical for this disease. Now appears to have more profound lung\n disease on chest x-ray, but was doing well in clinic one week prior to\n admission so unlikely to have sildenafil treatment failure.\n - cont sildenafil\n - cont lasix with caution given preload dependence of right ventricle\n - ECHO as above\n # Hypertension: Stable.\n - cont ACEi, CCB, beta blocker\n # Diabetes mellitus type II: Stable.\n - hold oral hypoglycemics\n - ISS\n # Chronic renal insufficiency: Creatinine at baseline of 1.5.\n - mucomyst and IVFs prior to CTA\n - renally dose meds\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2114-06-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577345, "text": "TITLE:\n Chief Complaint: 79 year-old female with history of sarcoidosis,\n moderate pulmonary hypertension, ILD, and diabetes mellitus type 2 who\n presents with acute on chronic dyspnea\n 24 Hour Events:\n Chest CTA: No PE, though evaluation of subsegmental vessels at left\n base is limited. New bilateral small effusions and compressive\n atalectasis with scattered thickened septal lines- ? edema, less likely\n changes related to sarcoid. D/W Dr. 2:00\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.7\n HR: 62 (62 - 89) bpm\n BP: 128/61(79) {106/48(62) - 169/118(122)} mmHg\n RR: 13 (13 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n Total In:\n 1,948 mL\n 639 mL\n PO:\n 740 mL\n 60 mL\n TF:\n IVF:\n 1,208 mL\n 579 mL\n Blood products:\n Total out:\n 625 mL\n 550 mL\n Urine:\n 625 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,323 mL\n 89 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 93%\n ABG: ////\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilaterally 1/3 up )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 228 K/uL\n 9.8 g/dL\n 29.1 %\n 10.6 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n WBC\n 10.6\n Hct\n 29.1\n Plt\n 228\n TropT\n <0.01\n Other labs: CK / CKMB / Troponin-T:97//<0.01, ALT / AST:13/\n Chest CTA: ***Prelim read***\n No PE, though evaluation of subsegmental vessels at left base is\n limited. New\n bilateral small effusions and compressive atalectasis with scattered\n thickened\n septal lines- ? edema, less likely changes related to sarcoid. D/W Dr.\n \n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n # Hypoxic respiratory failure: Her constellation of symptoms is most\n likely secondary to respiratory decompensation in the setting of a\n viral URI and poor respiratory reserve. Contributing factors to her\n poor respiratory function include known pulm hypertension and ILD,\n though it is unclear whether this is secondary to sarcoidosis or\n another etiology. Notably, her CXR appears more concerning when\n compared to prior imaging studies, as her interstitial changes are more\n marked, and this is concerning for progression of ILD. Arguing against\n progression of pulm htn is her overall improvement on sildenafil, as\n noted on her recent appointment with Dr. on . Other\n etiologies to consider include PE, pneumonia.\n - f/u final read of chest CTA\n - f/u rapid respiratory viral screen\n - sputum cx\n - ECHO to assess PA pressures\n - empiric vanc/levo to cover for pna pending culture data\n - cont sildenafil\n - wean shovel mask as tolerated\n - no ABG given absence of respiratory distress or mental status changes\n - ROMI\n # Pulmonary hypertension/right heart failure: Underwent right heart\n cath in and had PA pressure of 53/23. PA htn of unclear\n etiology, possibly secondary to sarcoidosis though pattern on chest CT\n not typical for this disease. Now appears to have more profound lung\n disease on chest x-ray, but was doing well in clinic one week prior to\n admission so unlikely to have sildenafil treatment failure.\n - cont sildenafil\n - cont lasix with caution given preload dependence of right ventricle\n - ECHO as above\n # Hypertension: Stable.\n - cont ACEi, CCB, beta blocker\n # Diabetes mellitus type II: Stable.\n - hold oral hypoglycemics\n - ISS\n # Chronic renal insufficiency: Creatinine at baseline of 1.5.\n - mucomyst and IVFs prior to CTA\n - renally dose meds\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2114-06-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577350, "text": "TITLE:\n Chief Complaint: 79 year-old female with history of sarcoidosis,\n moderate pulmonary hypertension, ILD, and diabetes mellitus type 2 who\n presents with acute on chronic dyspnea\n 24 Hour Events:\n Chest CTA: No PE, though evaluation of subsegmental vessels at left\n base is limited. New bilateral small effusions and compressive\n atalectasis with scattered thickened septal lines- ? edema, less likely\n changes related to sarcoid. D/W Dr. 2:00\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.7\n HR: 62 (62 - 89) bpm\n BP: 128/61(79) {106/48(62) - 169/118(122)} mmHg\n RR: 13 (13 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n Total In:\n 1,948 mL\n 639 mL\n PO:\n 740 mL\n 60 mL\n TF:\n IVF:\n 1,208 mL\n 579 mL\n Blood products:\n Total out:\n 625 mL\n 550 mL\n Urine:\n 625 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,323 mL\n 89 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 93%\n ABG: ////\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bilaterally 1/3 up )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 228 K/uL\n 9.8 g/dL\n 29.1 %\n 10.6 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n WBC\n 10.6\n Hct\n 29.1\n Plt\n 228\n TropT\n <0.01\n Other labs: CK / CKMB / Troponin-T:97//<0.01, ALT / AST:13/\n Chest CTA: ***Prelim read***\n No PE, though evaluation of subsegmental vessels at left base is\n limited. New\n bilateral small effusions and compressive atalectasis with scattered\n thickened\n septal lines- ? edema, less likely changes related to sarcoid. D/W Dr.\n \n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n # Hypoxic respiratory failure: Her constellation of symptoms is most\n likely secondary to respiratory decompensation in the setting of a\n viral URI and poor respiratory reserve. Contributing factors to her\n poor respiratory function include known pulm hypertension and ILD,\n though it is unclear whether this is secondary to sarcoidosis or\n another etiology. Chest CT with fluid in fissures with elevated BNP\n suggests diastolic dysfunction or heart failure, although this may be\n progression of ILD. Arguing against progression of pulm htn is her\n overall improvement on sildenafil, as noted on her recent appointment\n with Dr. on . Other etiologies to consider include\n pneumonia.\n - f/u final read of chest CTA\n - f/u rapid respiratory viral screen\n - sputum cx\n - ECHO to assess PA pressures\n - empiric vanc/levo to cover for pna pending culture data\n - cont sildenafil\n - wean shovel mask as tolerated\n - no ABG given absence of respiratory distress or mental status changes\n - ROMI\n - Trial of Lasix diuresis with goal of negative 500cc - 1 L\n # Pulmonary hypertension/right heart failure: Underwent right heart\n cath in and had PA pressure of 53/23. PA htn of unclear\n etiology, possibly secondary to sarcoidosis though pattern on chest CT\n not typical for this disease. Now appears to have more profound lung\n disease on chest x-ray, but was doing well in clinic one week prior to\n admission so unlikely to have sildenafil treatment failure.\n - cont sildenafil. require higher doses, but will reassess after\n diuresis.\n - cont lasix with caution given preload dependence of right ventricle\n - ECHO as above\n # Hypertension: Stable.\n - cont ACEi, CCB, beta blocker\n # Diabetes mellitus type II: Stable.\n - hold oral hypoglycemics\n - ISS\n # Chronic renal insufficiency: Creatinine at baseline of 1.5.\n - mucomyst and IVFs prior to CTA\n - renally dose meds\n # FEN: No IVF, replete electrolytes, diabetic diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2114-06-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577324, "text": "TITLE:\n Chief Complaint: 79 year-old female with history of sarcoidosis,\n moderate pulmonary hypertension, ILD, and diabetes mellitus type 2 who\n presents with acute on chronic dyspnea\n 24 Hour Events:\n Chest CTA: No PE, though evaluation of subsegmental vessels at left\n base is limited. New bilateral small effusions and compressive\n atalectasis with scattered thickened septal lines- ? edema, less likely\n changes related to sarcoid. D/W Dr. 2:00\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.7\n HR: 62 (62 - 89) bpm\n BP: 128/61(79) {106/48(62) - 169/118(122)} mmHg\n RR: 13 (13 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n Total In:\n 1,948 mL\n 639 mL\n PO:\n 740 mL\n 60 mL\n TF:\n IVF:\n 1,208 mL\n 579 mL\n Blood products:\n Total out:\n 625 mL\n 550 mL\n Urine:\n 625 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,323 mL\n 89 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 93%\n ABG: ////\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 228 K/uL\n 9.8 g/dL\n 29.1 %\n 10.6 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n WBC\n 10.6\n Hct\n 29.1\n Plt\n 228\n TropT\n <0.01\n Other labs: CK / CKMB / Troponin-T:97//<0.01, ALT / AST:13/\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n # Hypoxic respiratory failure: Her constellation of symptoms is most\n likely secondary to respiratory decompensation in the setting of a\n viral URI and poor respiratory reserve. Contributing factors to her\n poor respiratory function include known pulm hypertension and ILD,\n though it is unclear whether this is secondary to sarcoidosis or\n another etiology. Notably, her CXR appears more concerning when\n compared to prior imaging studies, as her interstitial changes are more\n marked, and this is concerning for progression of ILD. Arguing against\n progression of pulm htn is her overall improvement on sildenafil, as\n noted on her recent appointment with Dr. on . Other\n etiologies to consider include PE, pneumonia.\n - chest CTA to further characterize ILD, r/o PE\n - rapid respiratory viral screen\n - sputum cx\n - ECHO to assess PA pressures\n - hold off on solumedrol for now pending chest CT\n - empiric vanc/levo to cover for pna pending culture data\n - cont sildenafil\n - wean shovel mask as tolerated\n - no ABG given absence of respiratory distress or mental status changes\n - ROMI\n # Pulmonary hypertension/right heart failure: Underwent right heart\n cath in and had PA pressure of 53/23. PA htn of unclear\n etiology, possibly secondary to sarcoidosis though pattern on chest CT\n not typical for this disease. Now appears to have more profound lung\n disease on chest x-ray, but was doing well in clinic one week prior to\n admission so unlikely to have sildenafil treatment failure.\n - cont sildenafil\n - cont lasix with caution given preload dependence of right ventricle\n - ECHO as above\n # Hypertension: Stable.\n - cont ACEi, CCB, beta blocker\n # Diabetes mellitus type II: Stable.\n - hold oral hypoglycemics\n - ISS\n # Chronic renal insufficiency: Creatinine at baseline of 1.5.\n - mucomyst and IVFs prior to CTA\n - renally dose meds\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2114-06-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577335, "text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n pt is on high flow O2, 60 %.\n pt SOB after swabs for swine flu screening\n Action:\n pt continues on hi flow at 95% for trip to CTA\n CTA of chest\n Response:\n pt\ns o2 sats 91-96 on high flow at 95%\n Plan:\n wean o2 if possible,\n check results of CTA\n" }, { "category": "General", "chartdate": "2114-06-05 00:00:00.000", "description": "ICU Event Note", "row_id": 577351, "text": "Clinician: Attending\n CTA done, shows increased septal thickening, pleural effusions likely\n c/w edema. No PE.\n Remains on high flow FM (15L), increased from home 4L NC.\n Exam: 143/63 80 94-99% on high flow.\n Very well appearing, speaking full sentances, eating PO reg diet.\n Course crackles bilat lower lung fields. Systolic murmur. Moving air\n well. Abd NABS soft NDNT. Trace LE edema. No joint inflammation,\n rashes.\n No PE.\n ILD progression vs viral infection vs diastolic CHF in context of PH.\n 1. gentle diuresis with goal 1L net neg\n 2. echo today, BNP, cardiac \n 3. PAH continue sildenafil. As outpatient may need to increase\n dose of sildenafil to improve hemodynamics\n 4. remain in ICU with high FiO2 requirement\n critically ill with hypoxemic resp failure\n 35 minutes\n" }, { "category": "Nursing", "chartdate": "2114-06-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577448, "text": "Chief Complaint: 79 year-old female with history of sarcoidosis,\n moderate pulmonary hypertension, ILD, and diabetes mellitus type 2 who\n presents with acute on chronic dyspnea\n 24 Hour Events:\n Chest CTA: No PE, though evaluation of subsegmental vessels at left\n base is limited. New bilateral small effusions and compressive\n atalectasis with scattered thickened septal lines- ? edema, less likely\n changes related to sarcoid. D/W Dr. 2:00\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Bibasilar crackles, pt appears to have labored breathing, closed face\n mask at 90% (15 liters),\n Action:\n Resp parameters monitored, lasix 40mg iv given, attempt to change to\n nasal cannula at 4 liters resulted in drop in sat to 84%\n Response:\n Excellent diuresis from lasix, currently on nasal cannula at 4 liters\n and closed face tent at 90% with sat 92%, pt states that her breathing\n is better\n Plan:\n Continue to wean O2 as tolerated, ? further diuresis= pt given 2^nd\n dose of lasix 40mg iv at 1630\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Tolerating diet well, blood sugars 98-99\n Action:\n Blood sugars collected prior to meals\n Response:\n No sliding scale insulin required\n Plan:\n Continue to check blood sugars prior to meals and at bedtime and treat\n according to sliding scale\n" }, { "category": "Physician ", "chartdate": "2114-06-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577612, "text": "Chief Complaint:\n 24 Hour Events:\n - TTE showed increased dilation of RV, increased PAH (61mmgHg),\n worsening of free wall motion abnormality on right. EF 60%\n - I/O at 3pm only -500 so given another 40mg IV lasix but then am labs\n with creatinine increased (1.4->1.7) so stopped diuresing.\n - Dr. was concerned for CHF given effusions and thought best to\n trend BNP and lactate to see if getting better but agreed with holding\n further diuresis overnight given creatinine elevation\n - D/c'd abx as afebrile, no leukocytosis, and chest ct inconsistent\n with bacterial pna\n - flu swab negative ->d/c'd precautions\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 59 (58 - 81) bpm\n BP: 137/58(77) {72/39(45) - 152/76(86)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n Total In:\n 1,419 mL\n PO:\n 840 mL\n TF:\n IVF:\n 579 mL\n Blood products:\n Total out:\n 3,325 mL\n 400 mL\n Urine:\n 3,325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,906 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91%\n ABG: ///31/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: bilateral rales at lung bases, no wheezes or rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, HSM, late\n diastolic murmur, no rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ LE edema\n Labs / Radiology: AM chemistry pending at time of note.\n 229 K/uL\n 10.0 g/dL\n 95 mg/dL\n 1.7 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 23 mg/dL\n 104 mEq/L\n 143 mEq/L\n 30.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n 04:26 PM\n 06:04 AM\n WBC\n 10.6\n 9.8\n Hct\n 29.1\n 30.0\n Plt\n 228\n 229\n Cr\n 1.4\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 95\n Other labs: CK / CKMB / Troponin-T:87//<0.01, ALT / AST:13/, Ca++:8.9\n mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n TTE: The left atrium is mildly dilated. There is mild symmetric left\n ventricular hypertrophy. The left ventricular cavity size is normal.\n Overall left ventricular systolic function is normal (LVEF>55%). The\n right ventricular cavity is dilated with mild global free wall\n hypokinesis. There is abnormal septal motion/position consistent with\n right ventricular pressure/volume overload. The aortic valve leaflets\n are moderately thickened. There is mild aortic valve stenosis (valve\n area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. Trivial mitral regurgitation is\n seen. The left ventricular inflow pattern suggests impaired relaxation.\n The tricuspid valve leaflets are mildly thickened. There is severe\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n Compared with the prior study (images reviewed) of , the\n right ventricle appears slightly larger and free wall motion appears\n similar to slightly more depressed. Estimated pulmonary artery systolic\n pressure is now higher.\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n .\n # Hypoxic respiratory failure: Unclear etiology of hypoxia. Concerned\n initially for CHF and diuresed to negative 2L yesterday however with\n diuresis bumped creatinine/BUN.\n - follow BNPs and lactates to ascertain degree of CHF and whether\n perfusing as this may be able to sort out etiology of pleural\n effusions-> as still elevated BNP today would favor another 40mg IV\n Lasix especially since creatinine this am at baseline.\n - Flu swab negative\n - TTE with worsening PAH but this could be from hypoxic\n bronchoconstriction\n - sputum cx pending\n - empiric vanc/levo were discontinued as no evidence of infection\n clinically or on imaging\n - cont sildenafil and consider increasing dose if able to help PAH\n - wean shovel mask as tolerated\n - Consider RH cath for pulmonary and wedge pressures to ascertain CHF\n vs ILD\n # Pulmonary hypertension/right heart failure: Was doing well in clinic\n one week prior to admission so unlikely to have sildenafil treatment\n failure. TTE showed worsening PAH but unclear if this is related to\n hypoxic constriction as above.\n - cont sildenafil and consider increasing dose\n - cont lasix with caution given preload dependence of right ventricle\n - cte to f/u BNPs/lactate as above.\n # Chronic renal insufficiency: Creatinine at baseline of 1.5 prior to\n diuresis then bumped to 1.7 likely pre-renal azotemia from\n diuresis.\n - renally dose meds\n -trend creatinine\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n # Disposition: pending above\n" }, { "category": "Physician ", "chartdate": "2114-06-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577614, "text": "Chief Complaint:\n 24 Hour Events:\n - TTE showed increased dilation of RV, increased PAH (61mmgHg),\n worsening of free wall motion abnormality on right. EF 60%\n - I/O at 3pm only -500 so given another 40mg IV lasix but then am labs\n with creatinine increased (1.4->1.7) so stopped diuresing.\n - Dr. was concerned for CHF given effusions and thought best to\n trend BNP and lactate to see if getting better but agreed with holding\n further diuresis overnight given creatinine elevation\n - D/c'd abx as afebrile, no leukocytosis, and chest ct inconsistent\n with bacterial pna\n - flu swab negative ->d/c'd precautions\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 59 (58 - 81) bpm\n BP: 137/58(77) {72/39(45) - 152/76(86)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n Total In:\n 1,419 mL\n PO:\n 840 mL\n TF:\n IVF:\n 579 mL\n Blood products:\n Total out:\n 3,325 mL\n 400 mL\n Urine:\n 3,325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,906 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91%\n ABG: ///31/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: bilateral rales at lung bases, no wheezes or rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, HSM, late\n diastolic murmur, no rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ LE edema\n Labs / Radiology: AM chemistry pending at time of note.\n 229 K/uL\n 10.0 g/dL\n 95 mg/dL\n 1.7 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 23 mg/dL\n 104 mEq/L\n 143 mEq/L\n 30.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n 04:26 PM\n 06:04 AM\n WBC\n 10.6\n 9.8\n Hct\n 29.1\n 30.0\n Plt\n 228\n 229\n Cr\n 1.4\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 95\n Other labs: CK / CKMB / Troponin-T:87//<0.01, ALT / AST:13/, Ca++:8.9\n mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n TTE: The left atrium is mildly dilated. There is mild symmetric left\n ventricular hypertrophy. The left ventricular cavity size is normal.\n Overall left ventricular systolic function is normal (LVEF>55%). The\n right ventricular cavity is dilated with mild global free wall\n hypokinesis. There is abnormal septal motion/position consistent with\n right ventricular pressure/volume overload. The aortic valve leaflets\n are moderately thickened. There is mild aortic valve stenosis (valve\n area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. Trivial mitral regurgitation is\n seen. The left ventricular inflow pattern suggests impaired relaxation.\n The tricuspid valve leaflets are mildly thickened. There is severe\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n Compared with the prior study (images reviewed) of , the\n right ventricle appears slightly larger and free wall motion appears\n similar to slightly more depressed. Estimated pulmonary artery systolic\n pressure is now higher.\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n .\n # Hypoxic respiratory failure: Unclear etiology of hypoxia. Concerned\n initially for CHF and diuresed to negative 2L yesterday however with\n diuresis bumped creatinine/BUN.\n - follow BNPs and lactates to ascertain degree of CHF and whether\n perfusing as this may be able to sort out etiology of pleural\n effusions-> as still elevated BNP today would favor another 40mg IV\n Lasix especially since creatinine this am at baseline.\n - Flu swab negative\n - TTE with worsening PAH but this could be from hypoxic\n bronchoconstriction\n - sputum cx pending\n - empiric vanc/levo were discontinued as no evidence of infection\n clinically or on imaging\n - wean shovel mask as tolerated\n - Consider swan-ganz for pulmonary and wedge pressures to ascertain CHF\n vs ILD\n # Pulmonary hypertension/right heart failure: Was doing well in clinic\n one week prior to admission so unlikely to have sildenafil treatment\n failure. TTE showed worsening PAH but unclear if this is related to\n hypoxic constriction as above.\n - cont sildenafil and consider increasing dose\n - cont lasix with caution given preload dependence of right ventricle\n - cte to f/u BNPs/lactate as above.\n - consider steroids to treat ILD if swan shows worsening PAH and\n consider flolan in the future.\n # Chronic renal insufficiency: Creatinine at baseline of 1.5 prior to\n diuresis then bumped to 1.7 likely pre-renal azotemia from\n diuresis.\n - renally dose meds\n -trend creatinine\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n # Disposition: pending above\n" }, { "category": "Physician ", "chartdate": "2114-06-05 00:00:00.000", "description": "ICU Attending Note", "row_id": 577507, "text": "Clinician: Attending\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 79-year-old woman with respiratory distress on a background history of\n pulmonary hypertension (on sildenafil) and interstitial lung disease\n (hx of sarcoid, but currently other ILDs are under consideration;\n currently off prednisone for months).\n CTA done, shows increased septal thickening, pleural effusions possibly\n c/w edema vs progression of ILD. No PE. Viral DFA neg.\n Remains on high flow FM (15L), increased from home 4L NC.\n Exam: 143/63 80 94-99% on high flow.\n Very well appearing, speaking full sentances, eating PO reg diet.\n Course crackles bilat lower lung fields. Systolic murmur. Moving air\n well. Abd NABS soft NDNT. Trace LE edema. No joint inflammation,\n rashes.\n A/P: 79 yo woman with ILD admitted with acute decompensation and rise\n in oxygen requirement. No PE. ILD progression vs viral infection vs\n diastolic CHF in context of PH.\n 1. gentle diuresis with goal 1L net neg\n 2. echo today, BNP, cardiac \n 3. PAH continue sildenafil. As outpatient may need to increase\n dose of sildenafil to improve hemodynamics.\n 4. remain in ICU with high FiO2 requirement\n critically ill with hypoxemic resp failure\n 30 minutes\n" }, { "category": "Physician ", "chartdate": "2114-06-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577592, "text": "Chief Complaint:\n 24 Hour Events:\n - TTE showed increased dilation of RV, increased PAH (61mmgHg),\n worsening of free wall motion abnormality on right. EF 60%\n - I/O at 3pm only -500 so given another 40mg IV lasix but then am labs\n with creatinine increased (1.4->1.7) so stopped diuresing.\n - Dr. was concerned for CHF given effusions and thought best to\n trend BNP and lactate to see if getting better but agreed with holding\n further diuresis overnight given creatinine elevation\n - D/c'd abx as afebrile, no leukocytosis, and chest ct inconsistent\n with bacterial pna\n - flu swab negative ->d/c'd precautions\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 59 (58 - 81) bpm\n BP: 137/58(77) {72/39(45) - 152/76(86)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n Total In:\n 1,419 mL\n PO:\n 840 mL\n TF:\n IVF:\n 579 mL\n Blood products:\n Total out:\n 3,325 mL\n 400 mL\n Urine:\n 3,325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,906 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91%\n ABG: ///31/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: bilateral rales at lung bases, no wheezes or rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, HSM, late\n diastolic murmur, no rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ LE edema\n Labs / Radiology: AM chemistry pending at time of note.\n 229 K/uL\n 10.0 g/dL\n 95 mg/dL\n 1.7 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 23 mg/dL\n 104 mEq/L\n 143 mEq/L\n 30.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n 04:26 PM\n 06:04 AM\n WBC\n 10.6\n 9.8\n Hct\n 29.1\n 30.0\n Plt\n 228\n 229\n Cr\n 1.4\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 95\n Other labs: CK / CKMB / Troponin-T:87//<0.01, ALT / AST:13/, Ca++:8.9\n mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n .\n # Hypoxic respiratory failure: Unclear etiology of hypoxia. Concerned\n initially for CHF and diuresed to negative 2L yesterday however with\n diuresis bumped creatinine/BUN.\n - follow BNPs and lactates to ascertain degree of CHF and whether\n perfusing as this may be able to sort out etiology of pleural effusions\n - Flu swab negative\n - TTE with worsening PAH but this could be from hypoxic\n bronchoconstriction\n - sputum cx pending\n - empiric vanc/levo were discontinued as no evidence of infection\n clinically or on imaging\n - cont sildenafil and consider increasing dose if able to help PAH\n - wean shovel mask as tolerated\n # Pulmonary hypertension/right heart failure: Was doing well in clinic\n one week prior to admission so unlikely to have sildenafil treatment\n failure. TTE showed worsening PAH but unclear if this is related to\n hypoxic constriction as above.\n - cont sildenafil and consider increasing dose\n - cont lasix with caution given preload dependence of right ventricle\n # Chronic renal insufficiency: Creatinine at baseline of 1.5 prior to\n diuresis then bumped to 1.7 likely pre-renal azotemia from\n diuresis.\n - renally dose meds\n -trend creatinine\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2114-06-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577593, "text": "Chief Complaint:\n 24 Hour Events:\n - TTE showed increased dilation of RV, increased PAH (61mmgHg),\n worsening of free wall motion abnormality on right. EF 60%\n - I/O at 3pm only -500 so given another 40mg IV lasix but then am labs\n with creatinine increased (1.4->1.7) so stopped diuresing.\n - Dr. was concerned for CHF given effusions and thought best to\n trend BNP and lactate to see if getting better but agreed with holding\n further diuresis overnight given creatinine elevation\n - D/c'd abx as afebrile, no leukocytosis, and chest ct inconsistent\n with bacterial pna\n - flu swab negative ->d/c'd precautions\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 59 (58 - 81) bpm\n BP: 137/58(77) {72/39(45) - 152/76(86)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n Total In:\n 1,419 mL\n PO:\n 840 mL\n TF:\n IVF:\n 579 mL\n Blood products:\n Total out:\n 3,325 mL\n 400 mL\n Urine:\n 3,325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,906 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91%\n ABG: ///31/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: bilateral rales at lung bases, no wheezes or rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, HSM, late\n diastolic murmur, no rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ LE edema\n Labs / Radiology: AM chemistry pending at time of note.\n 229 K/uL\n 10.0 g/dL\n 95 mg/dL\n 1.7 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 23 mg/dL\n 104 mEq/L\n 143 mEq/L\n 30.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n 04:26 PM\n 06:04 AM\n WBC\n 10.6\n 9.8\n Hct\n 29.1\n 30.0\n Plt\n 228\n 229\n Cr\n 1.4\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 95\n Other labs: CK / CKMB / Troponin-T:87//<0.01, ALT / AST:13/, Ca++:8.9\n mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n TTE: The left atrium is mildly dilated. There is mild symmetric left\n ventricular hypertrophy. The left ventricular cavity size is normal.\n Overall left ventricular systolic function is normal (LVEF>55%). The\n right ventricular cavity is dilated with mild global free wall\n hypokinesis. There is abnormal septal motion/position consistent with\n right ventricular pressure/volume overload. The aortic valve leaflets\n are moderately thickened. There is mild aortic valve stenosis (valve\n area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. Trivial mitral regurgitation is\n seen. The left ventricular inflow pattern suggests impaired relaxation.\n The tricuspid valve leaflets are mildly thickened. There is severe\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n Compared with the prior study (images reviewed) of , the\n right ventricle appears slightly larger and free wall motion appears\n similar to slightly more depressed. Estimated pulmonary artery systolic\n pressure is now higher.\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n .\n # Hypoxic respiratory failure: Unclear etiology of hypoxia. Concerned\n initially for CHF and diuresed to negative 2L yesterday however with\n diuresis bumped creatinine/BUN.\n - follow BNPs and lactates to ascertain degree of CHF and whether\n perfusing as this may be able to sort out etiology of pleural effusions\n - Flu swab negative\n - TTE with worsening PAH but this could be from hypoxic\n bronchoconstriction\n - sputum cx pending\n - empiric vanc/levo were discontinued as no evidence of infection\n clinically or on imaging\n - cont sildenafil and consider increasing dose if able to help PAH\n - wean shovel mask as tolerated\n # Pulmonary hypertension/right heart failure: Was doing well in clinic\n one week prior to admission so unlikely to have sildenafil treatment\n failure. TTE showed worsening PAH but unclear if this is related to\n hypoxic constriction as above.\n - cont sildenafil and consider increasing dose\n - cont lasix with caution given preload dependence of right ventricle\n # Chronic renal insufficiency: Creatinine at baseline of 1.5 prior to\n diuresis then bumped to 1.7 likely pre-renal azotemia from\n diuresis.\n - renally dose meds\n -trend creatinine\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2114-06-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577578, "text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt requiring hi flow o2 plus nasal prongs to maintain sat 88-94\n Diuresing from lasix earlier in day\n Action:\n Turned , pt coughs , o2 on\n Cxr done\n Response:\n Sats remain 88-90 while asleep, 90-92 when awake.\n Weight down 4 kg\n Plan:\n OOB to chair, check cxr, monitor sats closely, ? repeat Lasix today\n" }, { "category": "Nursing", "chartdate": "2114-06-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 577872, "text": "79-year-old woman with respiratory distress on a background history of\n pulmonary hypertension (on sildenafil) and interstitial lung disease\n (hx of sarcoid, but currently other ILDs are under consideration;\n currently off prednisone for months).\n CTA done, shows increased septal thickening, pleural effusions possibly\n c/w edema vs progression of ILD. No PE. Viral DFA neg.\n Remains on high flow FM (15L), increased from home 4L NC.\n Exam: 143/63 80 94-99% on high flow.\n Very well appearing, speaking full sentances, eating PO reg diet.\n Course crackles bilat lower lung fields. Systolic murmur. Moving air\n well. Abd NABS soft NDNT. Trace LE edema. No joint inflammation,\n rashes.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n blood sugars 100-148 today\n Action:\n blood sugars checked prior to meals\n Response:\n no sliding scale insulin required this shift\n Plan:\n continue to check blood sugars qid and treat according to sliding scale\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n breath sounds clear in upper airways with slight crackles noted in\n right base, pt initially on 100% rebreather with sat 95%\n Action:\n lasix 40 mg iv given at 0800, o2 weaned to closed face mask and later\n to nasal cannula at 6 liters\n Response:\n minimal diuresis from lasix ( pt had received 3 doses yesterday), pt\n states that her breathing is comfortable, no distress noted, sats\n 88-92% . ( pt on home O2 at 4 liters with sat 92-94%)\n Plan:\n transfer to floor when bed available, continue to wean O2 as tolerated\n to home dose, continue lasix as ordered\n" }, { "category": "Nursing", "chartdate": "2114-06-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 577922, "text": "79-year-old woman with respiratory distress on a background history of\n pulmonary hypertension (on sildenafil) and interstitial lung disease\n (hx of sarcoid, but currently other ILDs are under consideration;\n currently off prednisone for months).\n CTA done, shows increased septal thickening, pleural effusions possibly\n c/w edema vs progression of ILD. No PE. Viral DFA neg.\n Remains on high flow FM (15L), increased from home 4L NC.\n Exam: 143/63 80 94-99% on high flow.\n Very well appearing, speaking full sentances, eating PO reg diet.\n Course crackles bilat lower lung fields. Systolic murmur. Moving air\n well. Abd NABS soft NDNT. Trace LE edema. No joint inflammation,\n rashes.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n blood sugars 100-148 today\n Action:\n blood sugars checked prior to meals\n Response:\n no sliding scale insulin required this shift\n Plan:\n continue to check blood sugars qid and treat according to sliding scale\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n breath sounds clear in upper airways with slight crackles noted in\n right base, pt initially on 100% rebreather with sat 95%\n Action:\n lasix 40 mg iv given at 0800, o2 weaned to closed face mask and later\n to nasal cannula at 6 liters\n Response:\n minimal diuresis from lasix ( pt had received 3 doses yesterday), pt\n states that her breathing is comfortable, no distress noted, sats\n 88-92% . ( pt on home O2 at 4 liters with sat 92-94%)\n Plan:\n transfer to floor when bed available, continue to wean O2 as tolerated\n to home dose, continue lasix as ordered\n Demographics\n Attending MD:\n \n Admit diagnosis:\n SHORTNESS OF BREATH\n Code status:\n Height:\n Admission weight:\n 81.9 kg\n Daily weight:\n 81.7 kg\n Allergies/Reactions:\n Aspirin\n Anemia; gastrit\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: CAD\n Additional history: Anemia, Renal insufficiency, pulmonary\n hypertension. hx sarcoid 30 yrs ago, with RLL lobectomy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:115\n D:52\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:66\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 92% %\n O2 flow:\n 6 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 960 mL\n 24h total out:\n 2,050 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 03:23 AM\n Potassium:\n 3.6 mEq/L\n 03:23 AM\n Chloride:\n 102 mEq/L\n 03:23 AM\n CO2:\n 30 mEq/L\n 03:23 AM\n BUN:\n 28 mg/dL\n 03:23 AM\n Creatinine:\n 1.7 mg/dL\n 03:23 AM\n Glucose:\n 100 mg/dL\n 03:23 AM\n Hematocrit:\n 31.3 %\n 03:23 AM\n Finger Stick Glucose:\n 187\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Physician ", "chartdate": "2114-06-06 00:00:00.000", "description": "Right Heart Catherization", "row_id": 577703, "text": "RIGHT HEART CATHERIZATION\n 6PM\n Asked by Dr. to assist with PA catheterization to assist in\n management of pulmonary hypertension. Fully explained to patient and\n daughter; all questions answered and patient wished to proceed.\n Venous access:\n Right IJ\n Ultrasound guidance\n Single pass\n 9 French introducer\n Right heart catheterization\n Single pass\n RA mean 16\n RV ~ 80-05 / 18\n PA ~ 80\n 85 / ~35\n CO/CI and PA sat pending CXR.\n No complications.\n" }, { "category": "Physician ", "chartdate": "2114-06-06 00:00:00.000", "description": "Right Heart Catherization", "row_id": 577706, "text": "RIGHT HEART CATHERIZATION\n 6PM\n Asked by Dr. to assist with PA catheterization to assist in\n management of pulmonary hypertension. Fully explained to patient and\n daughter; all questions answered and patient wished to proceed.\n Venous access:\n Right IJ\n Ultrasound guidance\n Single pass\n 9 French introducer\n Right heart catheterization\n Single pass\n RA mean 16\n RV ~ 80-05 / 18\n PA ~ 80\n 85 / ~35\n CO/CI and PA sat pending CXR.\n No complications.\n ------ Protected Section ------\n Addendum: Wedged at 49 cm (at hub of introducer, not sheath; at\n sheath, approx 53 cm). At conclusion of procedure, requires 1.5 cc for\n wedge and wedges very easily; returns to PA tracing when balloon\n deflated.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:31 ------\n" }, { "category": "Nursing", "chartdate": "2114-06-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 577904, "text": "79-year-old woman with respiratory distress on a background history of\n pulmonary hypertension (on sildenafil) and interstitial lung disease\n (hx of sarcoid, but currently other ILDs are under consideration;\n currently off prednisone for months).\n CTA done, shows increased septal thickening, pleural effusions possibly\n c/w edema vs progression of ILD. No PE. Viral DFA neg.\n Remains on high flow FM (15L), increased from home 4L NC.\n Exam: 143/63 80 94-99% on high flow.\n Very well appearing, speaking full sentances, eating PO reg diet.\n Course crackles bilat lower lung fields. Systolic murmur. Moving air\n well. Abd NABS soft NDNT. Trace LE edema. No joint inflammation,\n rashes.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n blood sugars 100-148 today\n Action:\n blood sugars checked prior to meals\n Response:\n no sliding scale insulin required this shift\n Plan:\n continue to check blood sugars qid and treat according to sliding scale\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n breath sounds clear in upper airways with slight crackles noted in\n right base, pt initially on 100% rebreather with sat 95%\n Action:\n lasix 40 mg iv given at 0800, o2 weaned to closed face mask and later\n to nasal cannula at 6 liters\n Response:\n minimal diuresis from lasix ( pt had received 3 doses yesterday), pt\n states that her breathing is comfortable, no distress noted, sats\n 88-92% . ( pt on home O2 at 4 liters with sat 92-94%)\n Plan:\n transfer to floor when bed available, continue to wean O2 as tolerated\n to home dose, continue lasix as ordered\n" }, { "category": "Nursing", "chartdate": "2114-06-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 577905, "text": "79-year-old woman with respiratory distress on a background history of\n pulmonary hypertension (on sildenafil) and interstitial lung disease\n (hx of sarcoid, but currently other ILDs are under consideration;\n currently off prednisone for months).\n CTA done, shows increased septal thickening, pleural effusions possibly\n c/w edema vs progression of ILD. No PE. Viral DFA neg.\n Remains on high flow FM (15L), increased from home 4L NC.\n Exam: 143/63 80 94-99% on high flow.\n Very well appearing, speaking full sentances, eating PO reg diet.\n Course crackles bilat lower lung fields. Systolic murmur. Moving air\n well. Abd NABS soft NDNT. Trace LE edema. No joint inflammation,\n rashes.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n blood sugars 100-148 today\n Action:\n blood sugars checked prior to meals\n Response:\n no sliding scale insulin required this shift\n Plan:\n continue to check blood sugars qid and treat according to sliding scale\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n breath sounds clear in upper airways with slight crackles noted in\n right base, pt initially on 100% rebreather with sat 95%\n Action:\n lasix 40 mg iv given at 0800, o2 weaned to closed face mask and later\n to nasal cannula at 6 liters\n Response:\n minimal diuresis from lasix ( pt had received 3 doses yesterday), pt\n states that her breathing is comfortable, no distress noted, sats\n 88-92% . ( pt on home O2 at 4 liters with sat 92-94%)\n Plan:\n transfer to floor when bed available, continue to wean O2 as tolerated\n to home dose, continue lasix as ordered\n" }, { "category": "Physician ", "chartdate": "2114-06-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577754, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 06:15 PM\n PA CATHETER - START 06:15 PM\n - Swan placed with elevated PCWP 22 and mean PAP 48 suggestive of fluid\n overload\n - Pt with sats 90-94 when awake but 88-90 while asleep -> put on 100%\n NRB with improvement to 93%\n - Received extra lasix 40mg IV x 1 as only 1.1 L neg at MN\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:34 PM\n Furosemide (Lasix) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (99\n HR: 69 (57 - 71) bpm\n BP: 134/57(75) {104/35(54) - 146/69(85)} mmHg\n RR: 21 (13 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n CVP: 7 (2 - 12)mmHg\n PAP: (69 mmHg) / (22 mmHg)\n PCWP: 22 (22 - 22) mmHg\n CO/CI (Thermodilution): (5.4 L/min) / ()\n SVR: 1,007 dynes*sec/cm5\n SV: 83 mL\n Total In:\n 1,200 mL\n PO:\n 1,200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,350 mL\n 900 mL\n Urine:\n 2,350 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,150 mL\n -900 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 94%\n ABG: ///30/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: bilateral rales at lung bases, no wheezes or rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, HSM, late\n diastolic murmur, no rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ LE edema\n Labs / Radiology\n 232 K/uL\n 10.5 g/dL\n 100 mg/dL\n 1.7 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 102 mEq/L\n 143 mEq/L\n 31.3 %\n 9.1 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n 04:26 PM\n 06:04 AM\n 03:17 PM\n 03:23 AM\n WBC\n 10.6\n 9.8\n 9.1\n Hct\n 29.1\n 30.0\n 31.3\n Plt\n \n Cr\n 1.4\n 1.7\n 1.5\n 1.6\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 95\n 100\n 75\n 100\n Other labs: CK / CKMB / Troponin-T:87//<0.01, ALT / AST:13/, Lactic\n Acid:0.8 mmol/L, Ca++:9.6 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n .\n # Hypoxic respiratory failure: Unclear etiology of hypoxia. Concerned\n initially for CHF and diuresed to negative 2L yesterday however with\n diuresis bumped creatinine/BUN.\n - follow BNPs and lactates to ascertain degree of CHF and whether\n perfusing as this may be able to sort out etiology of pleural\n effusions-> as still elevated BNP today would favor another 40mg IV\n Lasix especially since creatinine this am at baseline.\n - Flu swab negative\n - TTE with worsening PAH but this could be from hypoxic\n bronchoconstriction\n - sputum cx pending\n - empiric vanc/levo were discontinued as no evidence of infection\n clinically or on imaging\n - wean shovel mask as tolerated\n - Consider swan-ganz for pulmonary and wedge pressures to ascertain CHF\n vs ILD\n # Pulmonary hypertension/right heart failure: Was doing well in clinic\n one week prior to admission so unlikely to have sildenafil treatment\n failure. TTE showed worsening PAH but unclear if this is related to\n hypoxic constriction as above.\n - cont sildenafil and consider increasing dose\n - cont lasix with caution given preload dependence of right ventricle\n - cte to f/u BNPs/lactate as above.\n - consider steroids to treat ILD if swan shows worsening PAH and\n consider flolan in the future.\n # Chronic renal insufficiency: Creatinine at baseline of 1.5 prior to\n diuresis then bumped to 1.7 likely pre-renal azotemia from\n diuresis.\n - renally dose meds\n -trend creatinine\n ICU Care\n Nutrition: No IVF, replete electrolytes, regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 01:00 PM\n Cordis/Introducer - 06:15 PM\n PA Catheter - 06:15 PM\n Prophylaxis:\n DVT: Subcutaneous heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Daughter is \n Code status: Full\n Disposition: ICU\n" }, { "category": "Radiology", "chartdate": "2114-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081694, "text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate interval change\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with remote sarcoidosis, ILD, pulm HTN with b/l pleural\n effusions on CT chest\n REASON FOR THIS EXAMINATION:\n please evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with remote history of\n sarcoidosis, interstitial lung disease and pulmonary hypertension.\n\n Portable AP chest radiograph was compared to chest radiograph and\n chest CT.\n\n There is interval minimal worsening in degree of pulmonary edema which is also\n accompanied by increased pleural effusions and lower lung volumes. The\n appearance of the mediastinum including hilar lymphadenopathy did not\n significantly change as well as multiple pulmonary sutures. There is no\n evidence of pneumothorax.\n\n\n" }, { "category": "Nursing", "chartdate": "2114-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577750, "text": "79-year-old woman with respiratory distress on a background history of\n pulmonary hypertension (on sildenafil) and interstitial lung disease\n (hx of sarcoid, but currently other ILDs are under consideration;\n currently off prednisone for months). CTA done, shows increased septal\n thickening, pleural effusions possibly c/w edema vs progression of ILD.\n No PE. Viral DFA neg.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Tmax 99.5. PA cath in place. Persistent pulmonary hypertension.\n Received patient on 95% aerosol mask and n/prongs 5l. Breath sounds\n diminished at bases. Prolonged episode of desaturation to 87% when\n asleep.\n Action:\n Diuresed patient with scheduled lasix 40mg iv and x1 order of same.\n Foley cath placed for accuracy. O2 changed to 100% nrb mask.\n Response:\n Breath sounds remain diminished, sats 92-93%. Fluid balance -1,150\n yesterday (1734 at this time). PAS pressures 56-78, wedge 22\n reported by Dr . CO 5.4. cvp 3-6.\n Plan:\n Continue hemodynamic monitoring.\n Wedge to be done by team only.\n" }, { "category": "Physician ", "chartdate": "2114-06-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577830, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 06:15 PM\n PA CATHETER - START 06:15 PM\n - Swan placed with elevated PCWP 22 and mean PAP 48 suggestive of fluid\n overload\n - Pt with sats 90-94 when awake but 88-90 while asleep -> put on 100%\n NRB with improvement to 93%\n - Received extra lasix 40mg IV x 1 as only 1.1 L neg at MN\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:34 PM\n Furosemide (Lasix) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (99\n HR: 69 (57 - 71) bpm\n BP: 134/57(75) {104/35(54) - 146/69(85)} mmHg\n RR: 21 (13 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n CVP: 7 (2 - 12)mmHg\n PAP: (69 mmHg) / (22 mmHg)\n PCWP: 22 (22 - 22) mmHg\n CO/CI (Thermodilution): (5.4 L/min) / ()\n SVR: 1,007 dynes*sec/cm5\n SV: 83 mL\n Total In:\n 1,200 mL\n PO:\n 1,200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,350 mL\n 900 mL\n Urine:\n 2,350 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,150 mL\n -900 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 94%\n ABG: ///30/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: bilateral rales at lung bases, no wheezes or rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, HSM, late\n diastolic murmur, no rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ LE edema\n Labs / Radiology\n 232 K/uL\n 10.5 g/dL\n 100 mg/dL\n 1.7 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 102 mEq/L\n 143 mEq/L\n 31.3 %\n 9.1 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n 04:26 PM\n 06:04 AM\n 03:17 PM\n 03:23 AM\n WBC\n 10.6\n 9.8\n 9.1\n Hct\n 29.1\n 30.0\n 31.3\n Plt\n \n Cr\n 1.4\n 1.7\n 1.5\n 1.6\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 95\n 100\n 75\n 100\n Other labs: CK / CKMB / Troponin-T:87//<0.01, ALT / AST:13/, Lactic\n Acid:0.8 mmol/L, Ca++:9.6 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea likely diastolic CHF exacerbation not ILD\n .\n # Hypoxic respiratory failure: Swan-ganz placed and increased wedge\n pressures. Diuresed yesterday with 40mg IV lasix X 3. Net negative 1.1\n L: in 24hours and 900ml overnight. BNP decreased today suggesting less\n ventricular dilation. Lactate decreased suggesting better perfusion.\n Wedge 12 this morning.\n - Wean O2 as able (93% on 4L at home)\n - Convert to PO lasix\n - Pull swan\n # Pulmonary hypertension/right heart failure: Was doing well in clinic\n one week prior to admission so unlikely to have sildenafil treatment\n failure. TTE showed worsening PAH but likely from elevated wedge\n pressure.\n - increase dose of sildenafil\n - cont lasix PO\n # Chronic renal insufficiency: Creatinine at baseline of 1.5 prior to\n diuresis then bumped to 1.7 likely pre-renal azotemia from\n diuresis.\n - renally dose meds\n -trend creatinine\n ICU Care\n Nutrition: No IVF, replete electrolytes, regular diet\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 01:00 PM\n Cordis/Introducer - 06:15 PM->d/c cordis today\n PA Catheter - 06:15 PM\n Prophylaxis:\n DVT: Subcutaneous heparin\n Stress ulcer: PO diet\n VAP:\n Comments:\n Communication: Comments: Daughter is \n Code status: Full\n Disposition: call out to floor when on NC\n" }, { "category": "Nursing", "chartdate": "2114-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577740, "text": "79-year-old woman with respiratory distress on a background history of\n pulmonary hypertension (on sildenafil) and interstitial lung disease\n (hx of sarcoid, but currently other ILDs are under consideration;\n currently off prednisone for months).\n CTA done, shows increased septal thickening, pleural effusions possibly\n c/w edema vs progression of ILD. No PE. Viral DFA neg.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2114-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577751, "text": "79-year-old woman with respiratory distress on a background history of\n pulmonary hypertension (on sildenafil) and interstitial lung disease\n (hx of sarcoid, but currently other ILDs are under consideration;\n currently off prednisone for months). CTA done, shows increased septal\n thickening, pleural effusions possibly c/w edema vs progression of ILD.\n No PE. Viral DFA neg.\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Tmax 99.5. PA cath in place. Persistent pulmonary hypertension.\n Received patient on 95% aerosol mask and n/prongs 5l. Breath sounds\n diminished at bases. Prolonged episode of desaturation to 87% when\n asleep.\n Action:\n Diuresed patient with scheduled lasix 40mg iv and x1 order of same.\n Foley cath placed for accuracy. O2 changed to 100% nrb mask.\n Response:\n Breath sounds remain diminished, sats 92-93%. Fluid balance -1,150\n yesterday (1734 at this time). PAS pressures 56-78, wedge 22\n reported by Dr . CO 5.4. cvp 3-6.\n Plan:\n Continue hemodynamic monitoring.\n Wedge to be done by team only.\n Diurese as indicated.\n Emotional support of pt and family\n" }, { "category": "Physician ", "chartdate": "2114-06-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577797, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 06:15 PM\n PA CATHETER - START 06:15 PM\n - Swan placed with elevated PCWP 22 and mean PAP 48 suggestive of fluid\n overload\n - Pt with sats 90-94 when awake but 88-90 while asleep -> put on 100%\n NRB with improvement to 93%\n - Received extra lasix 40mg IV x 1 as only 1.1 L neg at MN\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:34 PM\n Furosemide (Lasix) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (99\n HR: 69 (57 - 71) bpm\n BP: 134/57(75) {104/35(54) - 146/69(85)} mmHg\n RR: 21 (13 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n CVP: 7 (2 - 12)mmHg\n PAP: (69 mmHg) / (22 mmHg)\n PCWP: 22 (22 - 22) mmHg\n CO/CI (Thermodilution): (5.4 L/min) / ()\n SVR: 1,007 dynes*sec/cm5\n SV: 83 mL\n Total In:\n 1,200 mL\n PO:\n 1,200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,350 mL\n 900 mL\n Urine:\n 2,350 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,150 mL\n -900 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 94%\n ABG: ///30/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: bilateral rales at lung bases, no wheezes or rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, HSM, late\n diastolic murmur, no rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ LE edema\n Labs / Radiology\n 232 K/uL\n 10.5 g/dL\n 100 mg/dL\n 1.7 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 102 mEq/L\n 143 mEq/L\n 31.3 %\n 9.1 K/uL\n [image002.jpg]\n 05:57 PM\n 05:30 AM\n 04:26 PM\n 06:04 AM\n 03:17 PM\n 03:23 AM\n WBC\n 10.6\n 9.8\n 9.1\n Hct\n 29.1\n 30.0\n 31.3\n Plt\n \n Cr\n 1.4\n 1.7\n 1.5\n 1.6\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 95\n 100\n 75\n 100\n Other labs: CK / CKMB / Troponin-T:87//<0.01, ALT / AST:13/, Lactic\n Acid:0.8 mmol/L, Ca++:9.6 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n .\n # Hypoxic respiratory failure: Swan-ganz placed and increased wedge\n pressures. Diuresed yesterday with 40mg IV lasix X 3. Net negative 1.1\n L: in 24hours and 900ml overnight. BNP decreased today suggesting less\n ventricular dilation. Lactate decreased suggesting better perfusion.\n - recheck wedge pressure to assess if adequate diuresis and continue to\n diurese if necessary\n - Flu swab negative\n - empiric vanc/levo were discontinued as no evidence of infection\n clinically or on imaging\n - wean shovel mask as tolerated\n # Pulmonary hypertension/right heart failure: Was doing well in clinic\n one week prior to admission so unlikely to have sildenafil treatment\n failure. TTE showed worsening PAH but likely from elevated wedge\n pressure.\n - cont sildenafil and consider increasing dose\n - cont lasix\n - cte to f/u BNPs/lactate as above.\n - consider steroids to treat ILD if swan shows worsening PAH and\n consider flolan in the future.\n # Chronic renal insufficiency: Creatinine at baseline of 1.5 prior to\n diuresis then bumped to 1.7 likely pre-renal azotemia from\n diuresis.\n - renally dose meds\n -trend creatinine\n ICU Care\n Nutrition: No IVF, replete electrolytes, regular diet\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 01:00 PM\n Cordis/Introducer - 06:15 PM\n PA Catheter - 06:15 PM\n Prophylaxis:\n DVT: Subcutaneous heparin\n Stress ulcer: PO diet\n VAP:\n Comments:\n Communication: Comments: Daughter is \n Code status: Full\n Disposition: call out to floor when on NC\n" }, { "category": "Physician ", "chartdate": "2114-06-07 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 577880, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 06:15 PM\n PA CATHETER - START 06:15 PM\n - Swan placed with elevated PCWP 22 and mean PAP 48 suggestive of fluid\n overload\n - Pt with sats 90-94 when awake but 88-90 while asleep -> put on 100%\n NRB with improvement to 93%\n - Received extra lasix 40mg IV x 1 as only 1.1 L neg at MN\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:34 PM\n Furosemide (Lasix) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (99\n HR: 69 (57 - 71) bpm\n BP: 134/57(75) {104/35(54) - 146/69(85)} mmHg\n RR: 21 (13 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n CVP: 7 (2 - 12)mmHg\n PAP: (69 mmHg) / (22 mmHg)\n PCWP: 22 (22 - 22) mmHg\n CO/CI (Thermodilution): (5.4 L/min) / ()\n SVR: 1,007 dynes*sec/cm5\n SV: 83 mL\n Total In:\n 1,200 mL\n PO:\n 1,200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,350 mL\n 900 mL\n Urine:\n 2,350 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,150 mL\n -900 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 94%\n ABG: ///30/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: bilateral rales at lung bases, no wheezes or rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, HSM, late\n diastolic murmur, no rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ LE edema\n Labs / Radiology\n 232 K/uL\n 10.5 g/dL\n 100 mg/dL\n 1.7 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 102 mEq/L\n 143 mEq/L\n 31.3 %\n 9.1 K/uL\n [image003.jpg]\n 05:57 PM\n 05:30 AM\n 04:26 PM\n 06:04 AM\n 03:17 PM\n 03:23 AM\n WBC\n 10.6\n 9.8\n 9.1\n Hct\n 29.1\n 30.0\n 31.3\n Plt\n \n Cr\n 1.4\n 1.7\n 1.5\n 1.6\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 95\n 100\n 75\n 100\n Other labs: CK / CKMB / Troponin-T:87//<0.01, ALT / AST:13/, Lactic\n Acid:0.8 mmol/L, Ca++:9.6 mg/dL, Mg++:2.3 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea likely diastolic CHF exacerbation not ILD\n .\n # Hypoxic respiratory failure: Swan-ganz placed and increased wedge\n pressures. Diuresed yesterday with 40mg IV lasix X 3. Net negative 1.1\n L: in 24hours and 900ml overnight. BNP decreased today suggesting less\n ventricular dilation. Lactate decreased suggesting better perfusion.\n Wedge 12 this morning.\n - Wean O2 as able (93% on 4L at home)\n - Convert to PO lasix\n - Pull swan\n # Pulmonary hypertension/right heart failure: Was doing well in clinic\n one week prior to admission so unlikely to have sildenafil treatment\n failure. TTE showed worsening PAH but likely from elevated wedge\n pressure.\n - increase dose of sildenafil\n - cont lasix PO\n # Chronic renal insufficiency: Creatinine at baseline of 1.5 prior to\n diuresis then bumped to 1.7 likely pre-renal azotemia from\n diuresis.\n - renally dose meds\n -trend creatinine\n ICU Care\n Nutrition: No IVF, replete electrolytes, regular diet\n Glycemic Control: ISS\n Lines:\n 18 Gauge - 01:00 PM\n Cordis/Introducer - 06:15 PM->d/c cordis today\n PA Catheter - 06:15 PM\n Prophylaxis:\n DVT: Subcutaneous heparin\n Stress ulcer: PO diet\n VAP:\n Comments:\n Communication: Comments: Daughter is \n Code status: Full\n Disposition: call out to floor when on NC\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with her\n note above, including assessment and plan.\n Events\n SGC placed last evening.\n Initial hemodynamics: PA 80/35 48, wedge 22\n Given 3 doses of IV lasix 40 mg\n PA this morning 65/23\n -1.1L/24h, -900cc since 12am\n Exam\n Tm 99 this morning\n 112.52 64 95%-100% on NRB\n PA 38/30 mean 34 wedge 12\n Looks well (though she always has) but still on NRB. Lung exam much\n improved with no crackles on left, much improved at right base. RRR no\n prominent second heart sound. Trace LE edema\n Labs\n Cr 1.7--> 1.5-- 1.7\n BNP down from 3100- 2600\n lactate 0.8 (2. on adm)\n A/P\n Hypoxemic resp failure attributable to PAH worsening due to volume\n overload/CHF. She came in with weight gain, LE edema, dypsnea. SGC\n indicated high filling pressure, demonstrating inadequate diuresis\n despite good urine output and rise in Cr.\n * Will slow down on diuresis at this point, to dosing\n * Anticipate we will see improvement in oxygenation\n Critically ill, 35 minutes\n Addendum:\n Prior to pulling SGC repeat PA 35/27 32 wedge 12\n ------ Protected Section Addendum Entered By: , MD\n on: 17:10 ------\n" }, { "category": "Nursing", "chartdate": "2114-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577888, "text": "79-year-old woman with respiratory distress on a background history of\n pulmonary hypertension (on sildenafil) and interstitial lung disease\n (hx of sarcoid, but currently other ILDs are under consideration;\n currently off prednisone for months).\n CTA done, shows increased septal thickening, pleural effusions possibly\n c/w edema vs progression of ILD. No PE. Viral DFA neg.\n Remains on high flow FM (15L), increased from home 4L NC.\n Exam: 143/63 80 94-99% on high flow.\n Very well appearing, speaking full sentances, eating PO reg diet.\n Course crackles bilat lower lung fields. Systolic murmur. Moving air\n well. Abd NABS soft NDNT. Trace LE edema. No joint inflammation,\n rashes.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n blood sugars 100-148 today\n Action:\n blood sugars checked prior to meals\n Response:\n no sliding scale insulin required this shift\n Plan:\n continue to check blood sugars qid and treat according to sliding scale\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n breath sounds clear in upper airways with slight crackles noted in\n right base, pt initially on 100% rebreather with sat 95%\n Action:\n lasix 40 mg iv given at 0800, o2 weaned to closed face mask and later\n to nasal cannula at 6 liters\n Response:\n minimal diuresis from lasix ( pt had received 3 doses yesterday), pt\n states that her breathing is comfortable, no distress noted, sats\n 88-92% . ( pt on home O2 at 4 liters with sat 92-94%)\n Plan:\n transfer to floor when bed available, continue to wean O2 as tolerated\n to home dose, continue lasix as ordered\n" }, { "category": "Physician ", "chartdate": "2114-06-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577710, "text": "Chief Complaint:\n 24 Hour Events:\n - TTE showed increased dilation of RV, increased PAH (61mmgHg),\n worsening of free wall motion abnormality on right. EF 60%\n - I/O at 3pm only -500 so given another 40mg IV lasix but then am labs\n with creatinine increased (1.4->1.7) so stopped diuresing.\n - Dr. was concerned for CHF given effusions and thought best to\n trend BNP and lactate to see if getting better but agreed with holding\n further diuresis overnight given creatinine elevation\n - D/c'd abx as afebrile, no leukocytosis, and chest ct inconsistent\n with bacterial pna\n - flu swab negative ->d/c'd precautions\n Allergies:\n Aspirin\n Anemia; gastrit\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Levofloxacin - 10:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 59 (58 - 81) bpm\n BP: 137/58(77) {72/39(45) - 152/76(86)} mmHg\n RR: 13 (13 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 81.7 kg (admission): 81.9 kg\n Total In:\n 1,419 mL\n PO:\n 840 mL\n TF:\n IVF:\n 579 mL\n Blood products:\n Total out:\n 3,325 mL\n 400 mL\n Urine:\n 3,325 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,906 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91%\n ABG: ///31/\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: bilateral rales at lung bases, no wheezes or rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, HSM, late\n diastolic murmur, no rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ LE edema\n Labs / Radiology: AM chemistry pending at time of note.\n 229 K/uL\n 10.0 g/dL\n 95 mg/dL\n 1.7 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 23 mg/dL\n 104 mEq/L\n 143 mEq/L\n 30.0 %\n 9.8 K/uL\n [image003.jpg]\n 05:57 PM\n 05:30 AM\n 04:26 PM\n 06:04 AM\n WBC\n 10.6\n 9.8\n Hct\n 29.1\n 30.0\n Plt\n 228\n 229\n Cr\n 1.4\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 95\n Other labs: CK / CKMB / Troponin-T:87//<0.01, ALT / AST:13/, Ca++:8.9\n mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n TTE: The left atrium is mildly dilated. There is mild symmetric left\n ventricular hypertrophy. The left ventricular cavity size is normal.\n Overall left ventricular systolic function is normal (LVEF>55%). The\n right ventricular cavity is dilated with mild global free wall\n hypokinesis. There is abnormal septal motion/position consistent with\n right ventricular pressure/volume overload. The aortic valve leaflets\n are moderately thickened. There is mild aortic valve stenosis (valve\n area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral\n valve leaflets are mildly thickened. Trivial mitral regurgitation is\n seen. The left ventricular inflow pattern suggests impaired relaxation.\n The tricuspid valve leaflets are mildly thickened. There is severe\n pulmonary artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n Compared with the prior study (images reviewed) of , the\n right ventricle appears slightly larger and free wall motion appears\n similar to slightly more depressed. Estimated pulmonary artery systolic\n pressure is now higher.\n Assessment and Plan\n 79 year-old female with history of sarcoidosis, moderate pulmonary\n hypertension, ILD, and diabetes mellitus type 2 who presents with acute\n on chronic dyspnea\n .\n # Hypoxic respiratory failure: Unclear etiology of hypoxia. Concerned\n initially for CHF and diuresed to negative 2L yesterday however with\n diuresis bumped creatinine/BUN.\n - follow BNPs and lactates to ascertain degree of CHF and whether\n perfusing as this may be able to sort out etiology of pleural\n effusions-> as still elevated BNP today would favor another 40mg IV\n Lasix especially since creatinine this am at baseline.\n - Flu swab negative\n - TTE with worsening PAH but this could be from hypoxic\n bronchoconstriction\n - sputum cx pending\n - empiric vanc/levo were discontinued as no evidence of infection\n clinically or on imaging\n - wean shovel mask as tolerated\n - Consider swan-ganz for pulmonary and wedge pressures to ascertain CHF\n vs ILD\n # Pulmonary hypertension/right heart failure: Was doing well in clinic\n one week prior to admission so unlikely to have sildenafil treatment\n failure. TTE showed worsening PAH but unclear if this is related to\n hypoxic constriction as above.\n - cont sildenafil and consider increasing dose\n - cont lasix with caution given preload dependence of right ventricle\n - cte to f/u BNPs/lactate as above.\n - consider steroids to treat ILD if swan shows worsening PAH and\n consider flolan in the future.\n # Chronic renal insufficiency: Creatinine at baseline of 1.5 prior to\n diuresis then bumped to 1.7 likely pre-renal azotemia from\n diuresis.\n - renally dose meds\n -trend creatinine\n # FEN: No IVF, replete electrolytes, regular diet\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: full, discussed with patient\n # Communication: Daughter is \n # Disposition: pending above\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n * -2L, CXR not significantly changed\n * BUN/Cr rise with lasix\n * afebrile, WBC nl, flu panel neg\n * 99.2 120/50 58 high flow FM\n * wbc 11--> 10\n * BNP 3100\n * TTE worse PH\n I am concerned about unexplained marked increase in oxygen requirement.\n Presentation not c/w infection. No improvement with diuresis. BNP\n increased from 1200--> 3000, which can be due to CHF or PAH\n progression. SGC may allow better understanding of filling pressures as\n well as sense of whether her PH has worsened and needs further\n pulmonary vasodilation. I would like to try that prior to committing\n her to high dose corticosteroids for empirical treatment of ILD flare.\n Discussed with Dr , who agrees.\n Critically ill, 35 minutes\n .\n ------ Protected Section Addendum Entered By: , MD\n on: 18:41 ------\n" }, { "category": "Nursing", "chartdate": "2114-06-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 577871, "text": ".H/O diabetes Mellitus (DM), Type II\n Assessment:\n blood sugars 100-148 today\n Action:\n blood sugars checked prior to meals\n Response:\n no sliding scale insulin required this shift\n Plan:\n continue to check blood sugars qid and treat according to sliding scale\n .H/O respiratory failure, acute (not ARDS/)\n Assessment:\n breath sounds clear in upper airways with slight crackles noted in\n right base, pt initially on 100% rebreather with sat 95%\n Action:\n lasix 40 mg iv given at 0800, o2 weaned to closed face mask and later\n to nasal cannula at 6 liters\n Response:\n minimal diuresis from lasix ( pt had received 3 doses yesterday), pt\n states that her breathing is comfortable, no distress noted, sats\n 88-92% . ( pt on home O2 at 4 liters with sat 92-94%)\n Plan:\n transfer to floor when bed available, continue to wean O2 as tolerated\n to home dose, continue lasix as ordered\n" }, { "category": "Radiology", "chartdate": "2114-06-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1081851, "text": " 6:20 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: PA catheter position; exclude PTX\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with pulmonary hypertension s/p PA catheter placement via\n right IJ.\n REASON FOR THIS EXAMINATION:\n PA catheter position; exclude PTX\n ______________________________________________________________________________\n WET READ: SBNa WED 6:53 PM\n Right IJ mid svc, no ptx, increased retrocardiac opacity could be atelectasis\n or infection.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with pulmonary hypertension\n after pulmonary artery catheter placement.\n\n The Swan-Ganz catheter tip appears to be at least at the level of right main\n pulmonary artery, but most likely at the level over the right interlobar\n pulmonary artery. The cardiomediastinal silhouette and parenchymal opacities\n are grossly unchanged with potentially slight improvement of superimposed\n pulmonary edema.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2125-11-05 00:00:00.000", "description": "Report", "row_id": 72023, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 65\nWeight (lb): 220\nBSA (m2): 2.06 m2\nBP (mm Hg): 118/67\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 13:41\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter\n(<2.1cm) with <35% decrease during respiration (estimated RA pressure\nindeterminate).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate regional\nLV systolic dysfunction. No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; basal inferior - hypo; mid inferior - hypo;\nanterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex -\nhypo; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular calcification.\nMild thickening of mitral valve chordae. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Borderline PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - poor subcostal views. Suboptimal image quality. Cardiology\nfellow involved with the patient's care was notified by telephone.\n\nConclusions:\nThe left atrium is elongated. The right atrial pressure is indeterminate.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nThere is moderate regional left ventricular systolic dysfunction with\nhypokinesis of the inferior wall and the distal half of the anterior septum\nand anterior walls, and the apex. The remaining segments contract normally\n(LVEF = 35 %). No masses or thrombi are seen in the left ventricle. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets are mildly thickened (?#). There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. Mild to moderate (+) mitral regurgitation is seen. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic dyfunction is more extensive and suggests multivessel CAD (or\nmyocarditis). The severity of mitral regurgitation is also increased.\n\n\n" }, { "category": "Echo", "chartdate": "2125-10-29 00:00:00.000", "description": "Report", "row_id": 72024, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Shortness of breath.\nHeight: (in) 65\nWeight (lb): 218\nBSA (m2): 2.05 m2\nBP (mm Hg): 101/34\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 09:18\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild-moderate\nregional LV systolic dysfunction. Apical LV aneurysm. Estimated cardiac index\nis normal (>=2.5L/min/m2). No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size. Focal apical hypokinesis of RV free\nwall. Paradoxic septal motion consistent with conduction\nabnormality/ventricular pacing.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Frequent\natrial premature beats.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild to moderate regional left\nventricular systolic dysfunction with severe hypokinesis of the distal septum,\nanterior and inferior walls. There is a small apical left ventricular aneurysm\nwith apical akinesis. The remaining segments contract normally (LVEF = 45 %).\nThe estimated cardiac index is normal (>=2.5L/min/m2). No masses or thrombi\nare seen in the left ventricle. Right ventricular chamber size is normal with\nfocal hypokinesis of the apical free wall. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Physiologic mitral\nregurgitation is seen (within normal limits). There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic\ndysfunction c/w CAD (distal LAD distribution).\nCompared with the prior study (images reviewed) of , basal septal and\nanterior function are improved, but apical dysfunction is now identified. Mild\npulmonary artery systolic hypertension is now identified.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Rehab Services", "chartdate": "2125-10-29 00:00:00.000", "description": "Bedside Swallow Evaluation", "row_id": 711890, "text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 75 y/o female with recent\nadmission with worsening back pain with MRI concerning for\nosteomyelitis of lumbar spine. She underwent a total laminectomy\nof L2-L4 , fusion of L2-L4 and segmental instrumentation of L2-L4\nwith implantation of autografts. Course was complicated by\nhypotension and decreased urine output. She was d/c'd to \n rehab on 12/4but readmitted to PSH on increased HR and low\nBP and she was transferred here on . TLC was placed in\nright groin and pt initially requiring NRB.\nPt is well known to our service from her last admission and was\nd/c'd on nectar thick liquids and soft solids with meds whole in\npuree. Pt requesting thin liquids on admission and we were\nreconsulted.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed in the CCU.\nCognition, language, speech, voice:\nPt was awake, alert and interactive, remembering me from her last\nadmission. Language was fluent but slow with hesitations. Speech\nand voice were wfl to palpation.\nTeeth: bottom teeth in fair condition - upper dentures in place\nSecretions: extremely dry oral mucosa, but no dried secretions\nORAL MOTOR EXAM:\nSymmetrical facial appearance with adequate lip seal and buccal\ntone. Tongue was at midline with functional strength and ROM.\nTremor appeared reduced from previous evaluation. Palatal\nelevation and gag were deferred.\nSWALLOWING ASSESSMENT:\nThe pt was seen with ice chips, thin liquids (tsp, straw,\nconsecutive), purees, ground solids and bite of soft solid. Pt\nphysically unable to masticate extremely dry oral mucosa,\neven after a full cup of water and she had to spit out the soft\nsolids. Ground solids were moistened and cleared with water, with\nonly mild residue. Pt had throat clearing x 1 when taking liquids\nwith solid still in her mouth, but otherwise without\nsigns of aspiration. O2 SATs remained stable at 94% with RR in\nthe low 30s (baseline before exam). Laryngeal elevation was\ntimely and wfl to palpation.\nSUMMARY / IMPRESSION:\nMs. thin liquids today, but had difficulty\nmasticating solids MS and extremely dry oral mucosa. I would\nstart her on thin liquids and moist, ground solids with continued\nsupervision for feeding. Pt may need breaks during meals her\ncurrent RR, but should tolerate well with a slow rate of intake.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 5.\nRECOMMENDATIONS:\n1. Suggest a PO diet of thin liquids and moist, ground solids.\nEncourage a slow rate of intake.\n2. Continue supervision for all PO intake.\n3. Meds whole with apple sauce.\n4. TID oral care.\n5. We will f/u later in the week to advance her as able.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 11:50-12:15\nTotal time: 45 minutes\n 12:29\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712068, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS rales bilat. Bilat LE pitting edema to thighs. Ascites. Severly dry\n oral mucosa.\n Action:\n ECHO12/07 - PND\n urine output very low. No response to Lasix as reported from the\n earlier shift.\n BNP high 37,627\n CXR w/ likely PNA and bilat pleural effusions\n Response:\n Poor UOP throughout shift with no response to IV fluid bolus . Started\n on Levo gtt.\n Plan:\n Continue to monitor for s/s worsening volume overload. Goal UOP >30\n ml/hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam as above. Received patient from CCU last night on vent\n CMV/60% /500/14. patient was intubated for MRI spine given poor resp\n status at baseline & patient had to lie flat. Received on Fentanyl @\n 75 mcg/kg/hr & midaz. @ 2mg/hr. Bilat breath sounds auscultated.\n Action:\n VBG drawn. Lactate : 1.2\n Multiple attempts to place A-line without success.\n Weaning sedation as tolerated.\n RSBI 49. ABG sent on . Electively extubated at 0515 hrs &\n placed on aerosol mask , weaned down to 35%. Please see flowsheet for\n details.\n Response:\n Satting at high 90\ns. RR 18-24 bpm ABG WNL.\n Plan:\n Continue to monitor resp status. VAP prevention. Monitor comfort and\n titrate sedation accordingly.\n Sepsis without organ dysfunction\n Assessment:\n Possible sources of infection- spine (from recent osteomyelitis),\n urine, lungs\n BP ranges 90s-100s/50s-60s.\n Access R femoral TLC placed in ED \n Poor urine output . MD made aware.\n Extremities cool, clammy.\n Action:\n MRI spine done to evaluate for osteo at prior surgical site;\n Spinal xray, CXR\n IV anbx: vanco, flagyl, Zosyn\n IVF boluses 500ml x 1. Urine output not responding to fluid bolus.\n MICU team aware.\n Recent C-diff on precautions though no stool since admission here.\n Po med held at his time as there is no OG tube placed. ( bcoz plan\n is to extubate this Am)\n Extubated today at 0515 am electively.\n Started on levphed gtt to keep MAP>60 & UOP >30 ml/hr.\n 40 Meq K to be repleted. 1 St bag on flow now.\n Response:\n UOP Improved after levo gtt (30-35 ml/hr).\n Plan:\n *Continue to closely monitor hemodynamics, urine output. Follow temp\n curve. Follow-up results of ECHO/ MRI and Xray of spine. At some point\n will need PICC placed in IR and R fem line to be d/c\n Impaired Skin Integrity\n Assessment:\n Please see metavision for details.\n Coccyx- appears red, +blanching. ?fungal rash vs pressure site. Mepilex\n from prior shift left in place.\n Surgical incision- lumbar spine/ L flank: steri strips\n Multiple skin tears around L flank incision and on arms/legs\n Action:\n Turned and repositioned q 2 hours.\n Critic aid ointment to exposed areas of coccyx and skin tears\n Response:\n No change this shift.\n Plan:\n Continue to monitor.\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712191, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. .\n Sepsis without organ dysfunction\n Assessment:\n Accepted on low dose Levophed @ 0.03 mcg/kg/min. ? source of sepsis\n (c-diff, SBP, vs progression of osteomyleitis). Afebrile. WBC=12.8.\n Action:\n Weaned to off with MAPS>65. On Abx. Paracentesis done with 2L removal,\n cx\ns sent. Albumin given post tap.\n Response:\n Slightly hypotensive post tap, 250 cc NS bolus given with improvement.\n Plan:\n Monitor temp and wbc. Cont with Abx. Send stool for c-diff. F/U cx\n F/u with ortho spine for results of spine MRI an plan. PICC to be\n placed in IR in am and fem line to be d/c\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 34/1.7 (baseline 0.6). Foley intact and patent draining yellow\n urine with sedimentation noted. Vanco trough 26.4.\n Action:\n Urine lytes sent. Vanco held.\n Response:\n Albumin given post paracentesis.\n Plan:\n Monitor I+O\ns, monitor lytes, Avoid nephrotoxins. Renally dose meds.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n s/p extubation (for MRI). LS with bibasilar crackles noted. L\n sided pleural effusion per CXR. Grossly volume overloaded. +ascites.\n Action:\n Fio2 weaned to off.\n Response:\n LS improved post paracentesis.\n Plan:\n Monitor resp status. Enc C+DB.\n Impaired Skin Integrity\n Assessment:\n Peri area remains reddened and excoriated. Spine incision steri-strips\n d/I, area remains pink without drainage. Mepilex to coccyx c/d/i.\n Action:\n Nystatin powder and protective barrier cream applied. T+R q2hr.\n Response:\n Unchanged this shift.\n Plan:\n Cont to monitor skin integrity. T+R q2hr. Apply protective barrier\n cream and nystatin powder as ordered.\n S&S eval done, + asp on thin liquids. Able to take nectar thick liquids\n and puree. Meds to be crushed in applesauce.\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 712196, "text": "Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "MICU Attending Event Note", "row_id": 711933, "text": "TITLE: MICU Attending\n Event Note / Family Meeting\n Patient developed hypercarbic respiratory failure c pCO2 71, good\n response to NPPV, but no UOP despite lasix. Echo with preserved /\n increased LVEF without progressive WMAs. Events discussed with family\n at bedside in detail, including husband, son and daughter. for\n now:\n - continue broad abx coverage for possible lung, urine, or\n spine infection\n - volume resuscitate\n 1L NS now given rising creatinine and\n poor UOP despite lasix challenge\n - check TSH, stim\n no clear reason for her to be\n adrenally insufficient\n - plain film / MRI of spine for possible progressive osteo /\n collection, spine team following closely\n - Will need elective intubation prior to MRI, family aware\n - arterial line for monitoring\n - await abd USG results prior to decision re paracentesis\n - above d/w team and MICU Green attending (Dr. ; will\n try to transfer to MICU 7 this PM\n , MD\n 60 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712015, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS rales bilat. Bilat LE pitting edema to thighs. Ascites. Severly dry\n oral mucosa.\n Action:\n ECHO12/07 - PND\n urine output very low. No response to Lasix as reported from the\n earlier shift.\n BNP high 37,627\n CXR w/ likely PNA and bilat pleural effusions\n Response:\n Poor UOP throughout shift with no response to IV fluid bolus\n Plan:\n Continue to monitor for s/s worsening volume overload.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam as above. Received patient from CCU last night on vent\n CMV/60% /500/14. patient was intubated for MRI spine given poor resp\n status at baseline & patient had to lie flat. Received on Fentanyl @\n 75 mcg/kg/hr & midaz. @ 2mg/hr. Bilat breath sounds auscultated.\n Action:\n VBG drawn-7.13/ CO2 74/ O2 88/26.\n Multiple attempts to place A-line without success.\n Weaned sedation as tolerated.\n Weaned vent parameter as tolerated. Please see flowsheet for details.\n Response:\n Satting at high 90\ns. RR 18 bpm.\n Plan:\n Continue to monitor resp status. VAP prevention. Monitor comfort and\n titrate sedation accordingly.\n Sepsis without organ dysfunction\n Assessment:\n Possible sources of infection- spine (from recent osteomyelitis),\n urine, lungs\n BP ranges y 90s-100s/50s-60s.\n *Access R femoral TLC placed in ED \n *Poor urine output as noted above\n *Extremities cool, clammy\n Action:\n *MRI spine to evaluate for osteo at prior surgical site; Spinal xray,\n CXR\n *IV anbx: vanco, flagyl, zosyn\n *IVF boluses 500ml x 2. UOP total to IVF boluses=70. MICU team aware.\n *Cortisone stim test\n *Recent C-diff on precautions though no stool since admission here\n Response:\n *Hemodynamics stable. Poor UOP.\n Plan:\n *Continue to closely monitor hemodynamics, urine output. Follow temp\n curve. Follow-up results of ECHO/ MRI and Xray of spine. At some point\n will need PICC placed in IR and R fem line to be d/c\n Impaired Skin Integrity\n Assessment:\n Please see metavision for details.\n Coccyx- appears red, +blanching. ?fungal rash vs pressure site. Mepilex\n from prior shift left in place.\n Surgical incision- lumbar spine/ L flank: steri strips\n Multiple skin tears around L flank incision and on arms/legs\n Action:\n Turned and repositioned q 2 hours. Critic aid ointment to exposed areas\n of coccyx and skin tears\n Response:\n No change this shift.\n Plan:\n Continue to monitor.\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712016, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS rales bilat. Bilat LE pitting edema to thighs. Ascites. Severly dry\n oral mucosa.\n Action:\n ECHO12/07 - PND\n urine output very low. No response to Lasix as reported from the\n earlier shift.\n BNP high 37,627\n CXR w/ likely PNA and bilat pleural effusions\n Response:\n Poor UOP throughout shift with no response to IV fluid bolus\n Plan:\n Continue to monitor for s/s worsening volume overload.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam as above. Received patient from CCU last night on vent\n CMV/60% /500/14. patient was intubated for MRI spine given poor resp\n status at baseline & patient had to lie flat. Received on Fentanyl @\n 75 mcg/kg/hr & midaz. @ 2mg/hr. Bilat breath sounds auscultated.\n Action:\n VBG drawn-7.13/ CO2 74/ O2 88/26.\n Multiple attempts to place A-line without success.\n Weaned sedation as tolerated.\n Weaned vent parameter as tolerated. Please see flowsheet for details.\n Response:\n Satting at high 90\ns. RR 18 bpm.\n Plan:\n Continue to monitor resp status. VAP prevention. Monitor comfort and\n titrate sedation accordingly.\n Sepsis without organ dysfunction\n Assessment:\n Possible sources of infection- spine (from recent osteomyelitis),\n urine, lungs\n BP ranges 90s-100s/50s-60s.\n Access R femoral TLC placed in ED \n Poor urine output . MD made aware.\n Extremities cool, clammy.\n Action:\n MRI spine done to evaluate for osteo at prior surgical site;\n Spinal xray, CXR\n IV anbx: vanco, flagyl, Zosyn\n IVF boluses 500ml x 1. UOP total to IVF boluses=70. MICU team aware.\n *Cortisone stim test\n *Recent C-diff on precautions though no stool since admission here\n Response:\n *Hemodynamics stable. Poor UOP.\n Plan:\n *Continue to closely monitor hemodynamics, urine output. Follow temp\n curve. Follow-up results of ECHO/ MRI and Xray of spine. At some point\n will need PICC placed in IR and R fem line to be d/c\n Impaired Skin Integrity\n Assessment:\n Please see metavision for details.\n Coccyx- appears red, +blanching. ?fungal rash vs pressure site. Mepilex\n from prior shift left in place.\n Surgical incision- lumbar spine/ L flank: steri strips\n Multiple skin tears around L flank incision and on arms/legs\n Action:\n Turned and repositioned q 2 hours. Critic aid ointment to exposed areas\n of coccyx and skin tears\n Response:\n No change this shift.\n Plan:\n Continue to monitor.\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711998, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n *LS rales\n up bilat. SPO2 initially >90 3L NC. +tachypnea w/ rr\n 30s-40s though denied feeling short of breath. Bilat LE pitting edema\n to thighs. Ascites. Severly dry oral mucosa.\n Action:\n *ECHO today- PND\n *IV lasix 40mg x one- no effect. Additional 100mg IV lasix in\n afternoon- no urine output.\n *BNP this afternoon= 37,627\n *CXR w/ likely PNA and bilat pleural effusions\n Response:\n Poor UOP throughout day with no response to IV lasix challenge.\n Plan:\n Continue to monitor for s/s worsening volume overload.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam as above. Initially on AM exam pt alert, oriented to self/\n hospital. Throughout morning, pt w/ decreasing mental status,\n decreasing UOP, increasing tachypnea and hypoxia to 80s on NRB, \n pallor.\n Action:\n *MICU team notified. ABG drawn-7.13/ 71/\n *Placed pt on NIMV w/ SPO2 up 100%. After a few hours, pt w/ increased\n alertness and able to transition over to NRB mask. Still tachypneic\n 30s-40s.\n *Multiple attempts to place A-line for frequent ABG checks without\n success\n Response:\n ABG on NIMV- 7.28/ CO2 44/ O2 59/22.\n Electively intubated at 1630 for MRI spine given poor resp status at\n baseline and length of time pt has to lie flat. Given 20 etomidate/\n 100mch succinocholine and intubated by anesthesia w/out issue. Fent/\n versed gtts for sedation.\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712000, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n *LS rales\n up bilat. SPO2 initially >90 3L NC. +tachypnea w/ rr\n 30s-40s though denied feeling short of breath. Bilat LE pitting edema\n to thighs. Ascites. Severly dry oral mucosa.\n Action:\n *ECHO today- PND\n *IV lasix 40mg x one- no effect. Additional 100mg IV lasix in\n afternoon- no urine output.\n *BNP this afternoon= 37,627\n *CXR w/ likely PNA and bilat pleural effusions\n Response:\n Poor UOP throughout day with no response to IV lasix challenge.\n Plan:\n Continue to monitor for s/s worsening volume overload.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam as above. Initially on AM exam pt alert, oriented to self/\n hospital. Throughout morning, pt w/ decreasing mental status,\n decreasing UOP, increasing tachypnea and hypoxia to 80s on NRB, \n pallor.\n Action:\n *MICU team notified. ABG drawn-7.13/ CO2 74/ O2 88/26.\n *Placed pt on NIMV w/ SPO2 up 100%. After a few hours, pt w/ increased\n alertness and able to transition over to NRB mask. Still tachypneic\n 30s-40s.\n *Multiple attempts to place A-line for frequent ABG checks without\n success\n Response:\n ABG on NIMV- 7.28/ CO2 44/ O2 59/22.\n Electively intubated at 1630 for MRI spine given poor resp status at\n baseline and length of time pt had to lie flat. Given 20 etomidatemg/\n 100mcg succinocholine and intubated by anesthesia w/out issue. Fent/\n versed gtts for sedation.\n Plan:\n Continue to monitor resp status. VAP prevention.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712001, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n *LS rales\n up bilat. SPO2 initially >90 3L NC. +tachypnea w/ rr\n 30s-40s though denied feeling short of breath. Bilat LE pitting edema\n to thighs. Ascites. Severly dry oral mucosa.\n Action:\n *ECHO today- PND\n *IV lasix 40mg x one- no effect. Additional 100mg IV lasix in\n afternoon- no urine output.\n *BNP this afternoon= 37,627\n *CXR w/ likely PNA and bilat pleural effusions\n Response:\n Poor UOP throughout day with no response to IV lasix challenge.\n Plan:\n Continue to monitor for s/s worsening volume overload.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam as above. Initially on AM exam pt alert, oriented to self/\n hospital. Throughout morning, pt w/ decreasing mental status,\n decreasing UOP, increasing tachypnea and hypoxia to 80s on NRB, \n pallor. NIBP down to 70s-80s/50s.\n Action:\n *MICU team notified. ABG drawn-7.13/ CO2 74/ O2 88/26.\n *Placed pt on NIMV w/ SPO2 up 100%. Briefly on dopamine 10mcg/kg/min\n (w/ some sinus tach to 120s while it was running at 10mcg.) After a\n few hours, pt w/ increased alertness and able to transition over to NRB\n mask. Still tachypneic 30s-40s.\n *Multiple attempts to place A-line for frequent ABG checks without\n success.\n Response:\n ABG on NIMV- 7.28/ CO2 44/ O2 59/22. BP up 100s/60s- able to wean\n dopamine off within one hour.\n Electively intubated at 1630 for MRI spine given poor resp status at\n baseline and length of time pt had to lie flat. Given 20 etomidate mg/\n 100mcg succinocholine and intubated by anesthesia w/out issue. Fent/\n versed gtts for sedation.\n Plan:\n Continue to monitor resp status. VAP prevention. Monitor comfort and\n titrate sedation accordingly.\n Sepsis without organ dysfunction\n Assessment:\n *Possible sources of infection- spine (from recent osteomyelitis),\n urine, lungs\n *Tachycardic 90s-100s ST w/ PVCs/APCs. Hypothermic 96 range rectally-\n pt reports feeling hot and repeatedly kicks off blankets. BP mainly\n 90s-110s/50s-60s.\n *Access R femoral TLC placed in ED \n *Poor urine output as noted above\n *Extremities cool, clammy\n Action:\n *MRI spine to evaluate for osteo at prior surgical site\n *CXR\n *Blood Cxs drawn overnight\n *Cortisone stim test\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712002, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n *LS rales\n up bilat. SPO2 initially >90 3L NC. +tachypnea w/ rr\n 30s-40s though denied feeling short of breath. Bilat LE pitting edema\n to thighs. Ascites. Severly dry oral mucosa.\n Action:\n *ECHO today- PND\n *IV lasix 40mg x one- no effect. Additional 100mg IV lasix in\n afternoon- no urine output.\n *BNP this afternoon= 37,627\n *CXR w/ likely PNA and bilat pleural effusions\n Response:\n Poor UOP throughout day with no response to IV lasix challenge.\n Plan:\n Continue to monitor for s/s worsening volume overload.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam as above. Initially on AM exam pt alert, oriented to self/\n hospital. Throughout morning, pt w/ decreasing mental status,\n decreasing UOP, increasing tachypnea and hypoxia to 80s on NRB, \n pallor. NIBP down to 70s-80s/50s.\n Action:\n *MICU team notified. ABG drawn-7.13/ CO2 74/ O2 88/26.\n *Placed pt on NIMV w/ SPO2 up 100%. Briefly on dopamine 10mcg/kg/min\n (w/ some sinus tach to 120s while it was running at 10mcg.) After a\n few hours, pt w/ increased alertness and able to transition over to NRB\n mask. Still tachypneic 30s-40s.\n *Multiple attempts to place A-line for frequent ABG checks without\n success.\n Response:\n ABG on NIMV- 7.28/ CO2 44/ O2 59/22. BP up 100s/60s- able to wean\n dopamine off within one hour.\n Electively intubated at 1630 for MRI spine given poor resp status at\n baseline and length of time pt had to lie flat. Given 20 etomidate mg/\n 100mcg succinocholine and intubated by anesthesia w/out issue. Fent/\n versed gtts for sedation.\n Plan:\n Continue to monitor resp status. VAP prevention. Monitor comfort and\n titrate sedation accordingly.\n Sepsis without organ dysfunction\n Assessment:\n *Possible sources of infection- spine (from recent osteomyelitis),\n urine, lungs\n *Tachycardic 90s-100s ST w/ PVCs/APCs. Hypothermic 96 range rectally-\n pt reports feeling hot and repeatedly kicks off blankets. BP mainly\n 90s-110s/50s-60s.\n *Access R femoral TLC placed in ED \n *Poor urine output as noted above\n *Extremities cool, clammy\n Action:\n *MRI spine to evaluate for osteo at prior surgical site; Spinal xray,\n CXR\n *IV anbx: vanco, flagyl, zosyn\n *IVF boluses 500ml x 2. UOP total to IVF boluses=70. MICU team aware.\n *Cortisone stim test\n *Recent C-diff on precautions though no stool since admission here\n Response:\n *Hemodynamics stable. Poor UOP.\n Plan:\n *Continue to closely monitor hemodynamics, urine output. Follow temp\n curve. Follow-up results of ECHO/ MRI and Xray of spine. At some point\n will need PICC placed in IR and R fem line to be d/c\n Impaired Skin Integrity\n Assessment:\n Please see metavision for details.\n Coccyx- appears red, +blanching. ?fungal rash vs pressure site. Mepilex\n from prior shift left in place.\n Surgical incision- lumbar spine/ L flank: steri strips\n Multiple skin tears around L flank incision and on arms/legs\n Action:\n Turned and repositioned q 2 hours. Critic aid ointment to exposed areas\n of coccyx and skin tears\n Response:\n No change this shift.\n Plan:\n Continue to monitor.\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712018, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS rales bilat. Bilat LE pitting edema to thighs. Ascites. Severly dry\n oral mucosa.\n Action:\n ECHO12/07 - PND\n urine output very low. No response to Lasix as reported from the\n earlier shift.\n BNP high 37,627\n CXR w/ likely PNA and bilat pleural effusions\n Response:\n Poor UOP throughout shift with no response to IV fluid bolus\n Plan:\n Continue to monitor for s/s worsening volume overload.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam as above. Received patient from CCU last night on vent\n CMV/60% /500/14. patient was intubated for MRI spine given poor resp\n status at baseline & patient had to lie flat. Received on Fentanyl @\n 75 mcg/kg/hr & midaz. @ 2mg/hr. Bilat breath sounds auscultated.\n Action:\n VBG drawn. Lactate : 1.2\n Multiple attempts to place A-line without success.\n Weaning sedation as tolerated.\n Weaning vent parameter as tolerated. Please see flowsheet for\n details.\n Response:\n Satting at high 90\ns. RR 18 bpm.\n Plan:\n Continue to monitor resp status. VAP prevention. Monitor comfort and\n titrate sedation accordingly.\n Sepsis without organ dysfunction\n Assessment:\n Possible sources of infection- spine (from recent osteomyelitis),\n urine, lungs\n BP ranges 90s-100s/50s-60s.\n Access R femoral TLC placed in ED \n Poor urine output . MD made aware.\n Extremities cool, clammy.\n Action:\n MRI spine done to evaluate for osteo at prior surgical site;\n Spinal xray, CXR\n IV anbx: vanco, flagyl, Zosyn\n IVF boluses 500ml x 1. Urine output not responding to fluid bolus.\n MICU team aware.\n Recent C-diff on precautions though no stool since admission here.\n Po med held at his time as there is no OG tube placed. ( bcoz plan is\n to extubate this Am).\n Response:\n Poor UOP.\n Plan:\n *Continue to closely monitor hemodynamics, urine output. Follow temp\n curve. Follow-up results of ECHO/ MRI and Xray of spine. At some point\n will need PICC placed in IR and R fem line to be d/c\nd. If SBP drops\n below 90\ns, may consider to start neo gtt.\n Impaired Skin Integrity\n Assessment:\n Please see metavision for details.\n Coccyx- appears red, +blanching. ?fungal rash vs pressure site. Mepilex\n from prior shift left in place.\n Surgical incision- lumbar spine/ L flank: steri strips\n Multiple skin tears around L flank incision and on arms/legs\n Action:\n Turned and repositioned q 2 hours.\n Critic aid ointment to exposed areas of coccyx and skin tears\n Response:\n No change this shift.\n Plan:\n Continue to monitor.\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "MICU Attending Progress Note", "row_id": 711909, "text": "TITLE: MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. Plan of care\n reviewed in multidisciplinary rounds with CCU house and RN,\n including the assessment and plan. I would emphasize the following\n points: 75F PAF, CAD c low EF, DM, HTN, fatty liver, vertebral osteo\n s/p laminectomy L2-L4, recent c. diff. p/w increased respiratory rate\n at rehab, hypotensive, rx dopa / NPPV / volume o/n with improvement.\n CTA s pneumonia or clot per OSH report.\n Exam notable for Tmin 96.0 BP 110/70 HR 90-110 RR 20-30 with sat 92 on\n 2LNC. Arousable but disoriented. Elevated JVD. Coarse BS B. RRR s1s2.\n Soft, distended, +BS, no clear fluid wave. 3+ edema, cool extremities\n with decreased pulses. Labs notable for WBC 16K, HCT 33, K+ 3.9, Cr\n 1.3, lactate 2.5. CXR with large heart, LLL collapse, mod CHF changes,\n EKG old ASMI.\n Agree with plan to manage respiratory distress with BNP, ABG now; will\n start lasix for likely element of volume overload and will monitor in\n CCU for possible intubation / NPPV. For hypotension, will pan cx, cont\n vanco / flagyl and zosyn given possible sepsis. In addition, will cycle\n and recheck echo given CAD and low EF, ? increasing PHTN given ascites\n and exam findings, which are concerning for cardiogenic shock. For\n ascites, follow LFTs, check albumin, check abdmoninal USG with flows\n given OSH findings; will tap for dx if ascites is present. Will d/w\n spine re reimaging back for possible collection, vanco x6w. AF stable -\n now in NSR, hold off on home metoprolol for the moment and d/w PCP re\n long term anticoagulation. For psych d/o and anxiety, will continue\n home meds and d/w family re baseline. For c. diff, recheck stool cx and\n continue flagyl while on vanco for spinal osteo. Will change CVL to\n PICC and continue remainder of supportive care. Remainder of plan as\n outlined above.\n Patient is critically ill\n Total time: 50 min\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711990, "text": "Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711993, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema. Abd soft NT ND\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n *LS rales\n up bilat. SPO2 initially >90 3L NC. +tachypnea w/ rr\n 30s-40s though denied feeling short of breath. Bilat LE pitting edema\n to thighs. Ascites. Severly dry oral mucosa.\n Action:\n *ECHO today- PND\n *IV lasix 40mg x one- no effect. Additional 100mg IV lasix in\n afternoon- no urine output.\n *BNP this afternoon= 37,627\n *CXR w/ likely PNA and bilat pleural effusions\n Response:\n Poor UOP throughout day with no response to IV lasix challenge.\n Plan:\n Continue to monitor for s/s worsening volume overload.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam as above. Initially on AM exam pt alert, oriented to self/\n hospital. Throughout morning, pt w/ decreasing mental status,\n decreasing UOP, increasing tachypnea and hypoxia to 80s on NRB, \n pallor.\n Action:\n *MICU team notified. ABG drawn-7.13/ 71/\n *Placed pt on NIMV w/ SPO2 up 100%. After a few hours, pt w/ increased\n alertness and able to transition over to NRB mask. Still tachypneic\n 30s-40s.\n *Multiple attempts to place A-line for frequent ABG checks without\n success\n Response:\n ABG on NIMV- 7.28/ CO2 44/ O2 59/22.\n Electively intubated at 1630 for MRI spine given poor resp status at\n baseline and length of time pt has to lie flat. Given 20 etomidate/\n 100mch succinocholine and intubated by anesthesia w/out issue. Fent/\n versed gtts for sedation.\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712174, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. .\n Sepsis without organ dysfunction\n Assessment:\n Accepted on low dose Levophed @ 0.03 mcg/kg/min. ? source of sepsis\n (c-diff, SBP, vs progression of osteomyleitis). Afebrile. WBC=12.8.\n Action:\n Weaned to off with MAPS>65. On Abx. Paracentesis done with 2L removal,\n cx\ns sent. Albumin given post tap.\n Response:\n Slightly hypotensive post tap, 250 cc NS bolus given with improvement.\n Plan:\n Monitor temp and wbc. Cont with Abx. Send stool for c-diff. F/U cx\n F/u with ortho spine for results of spine MRI an plan. PICC to be\n placed in IR in am and fem line to be d/c\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 34/1.7 (baseline 0.6). Foley intact and patent draining yellow\n urine with sedimentation noted. Vanco trough 26.4.\n Action:\n Urine lytes sent. Vanco held.\n Response:\n Albumin given post paracentesis.\n Plan:\n Monitor I+O\ns, monitor lytes, Avoid nephrotoxins. Renally dose meds.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n s/p extubation (for MRI). LS with bibasilar crackles noted. L\n sided pleural effusion per CXR. Grossly volume overloaded. +ascites.\n Action:\n Fio2 weaned to off.\n Response:\n LS improved post paracentesis.\n Plan:\n Monitor resp status. Enc C+DB.\n Impaired Skin Integrity\n Assessment:\n Peri area remains reddened and excoriated. Spine incision steri-strips\n d/I, area remains pink without drainage. Mepilex to coccyx c/d/i.\n Action:\n Nystatin powder and protective barrier cream applied. T+R q2hr.\n Response:\n Unchanged this shift.\n Plan:\n Cont to monitor skin integrity. T+R q2hr. Apply protective barrier\n cream and nystatin powder as ordered.\n S&S eval done, + asp on thin liquids. Able to take nectar thick liquids\n and puree. Meds to be crushed in applesauce.\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711806, "text": "75yo recently admitted () with worsening back pain MRI concerning\n for osteomyelieitis of lumbar spine. Underwent a total laminecomy of\n l2-l4, fusion of l2-l4 segmental instrumentation of L2-L4 and\n implantation of autografts. In OR cultures had 1+ poly on gram stain\n of tissue and cx were NGSF. This was c/b hypotension and decreased\n uo. She was D/c'd on to Rehab. Admitted to \n with ^ hr and low bp. There they started iv dopamine and transferred\n to for further management,. In ew TLC was placed in R groin. 1\n L ns bolus was given and dopamine was dc'd. She was initially on 100%\n NRB with sats in the upper 90's this has been decreased to 3lnp with\n sats in the mid 90's. Her RR conts to be elevated in the 30's. Bp\n 100-120's after bolus with hr 90-100's sr/st. She is being transferred\n to MICU covered by CCU team for further management.\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712050, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema.\n Heart failure (CHF), Systolic, Acute on Chronic\n Assessment:\n LS rales bilat. Bilat LE pitting edema to thighs. Ascites. Severly dry\n oral mucosa.\n Action:\n ECHO12/07 - PND\n urine output very low. No response to Lasix as reported from the\n earlier shift.\n BNP high 37,627\n CXR w/ likely PNA and bilat pleural effusions\n Response:\n Poor UOP throughout shift with no response to IV fluid bolus . Started\n on Levo gtt.\n Plan:\n Continue to monitor for s/s worsening volume overload. Goal UOP >30\n ml/hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam as above. Received patient from CCU last night on vent\n CMV/60% /500/14. patient was intubated for MRI spine given poor resp\n status at baseline & patient had to lie flat. Received on Fentanyl @\n 75 mcg/kg/hr & midaz. @ 2mg/hr. Bilat breath sounds auscultated.\n Action:\n VBG drawn. Lactate : 1.2\n Multiple attempts to place A-line without success.\n Weaning sedation as tolerated.\n RSBI 49. ABG sent on . Electively extubated at 0515 hrs &\n placed on aerosol mask , weaned down to 35%. Please see flowsheet for\n details.\n Response:\n Satting at high 90\ns. RR 18-24 bpm ABG WNL.\n Plan:\n Continue to monitor resp status. VAP prevention. Monitor comfort and\n titrate sedation accordingly.\n Sepsis without organ dysfunction\n Assessment:\n Possible sources of infection- spine (from recent osteomyelitis),\n urine, lungs\n BP ranges 90s-100s/50s-60s.\n Access R femoral TLC placed in ED \n Poor urine output . MD made aware.\n Extremities cool, clammy.\n Action:\n MRI spine done to evaluate for osteo at prior surgical site;\n Spinal xray, CXR\n IV anbx: vanco, flagyl, Zosyn\n IVF boluses 500ml x 1. Urine output not responding to fluid bolus.\n MICU team aware.\n Recent C-diff on precautions though no stool since admission here.\n Po med held at his time as there is no OG tube placed. ( bcoz plan\n is to extubate this Am)\n Extubated today at 0515 am electively.\n Started on levphed gtt to keep MAP>60 & UOP >30 ml/hr.\n Response:\n UOP Improved after levo gtt .\n Plan:\n *Continue to closely monitor hemodynamics, urine output. Follow temp\n curve. Follow-up results of ECHO/ MRI and Xray of spine. At some point\n will need PICC placed in IR and R fem line to be d/c\n Impaired Skin Integrity\n Assessment:\n Please see metavision for details.\n Coccyx- appears red, +blanching. ?fungal rash vs pressure site. Mepilex\n from prior shift left in place.\n Surgical incision- lumbar spine/ L flank: steri strips\n Multiple skin tears around L flank incision and on arms/legs\n Action:\n Turned and repositioned q 2 hours.\n Critic aid ointment to exposed areas of coccyx and skin tears\n Response:\n No change this shift.\n Plan:\n Continue to monitor.\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712172, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. .\n Sepsis without organ dysfunction\n Assessment:\n Accepted on low dose Levophed @ 0.03 mcg/kg/min. ? source of sepsis\n (c-diff, SBP, vs progression of osteomyleitis). Afebrile. WBC=12.8.\n Action:\n Weaned to off with MAPS>65. On Abx. Paracentesis done with 2L removal,\n cx\ns sent. Albumin given post tap.\n Response:\n Slightly hypotensive post tap, 250 cc NS bolus given with improvement.\n Plan:\n Monitor temp and wbc. Cont with Abx. Send stool for c-diff. F/U cx\n F/u with ortho spine for\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 34/1.7 (baseline 0.6). Foley intact and patent draining yellow\n urine with sedimentation noted. Vanco trough 26.4.\n Action:\n Urine lytes sent. Vanco held.\n Response:\n Albumin given post paracentesis.\n Plan:\n Monitor I+O\ns, monitor lytes, Avoid nephrotoxins. Renally dose meds.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n s/p extubation (for MRI). LS with bibasilar crackles noted. L\n sided pleural effusion per CXR. Grossly volume overloaded. +ascites.\n Action:\n Fio2 weaned to off.\n Response:\n LS improved post paracentesis.\n Plan:\n Monitor resp status. Enc C+DB.\n Impaired Skin Integrity\n Assessment:\n Peri area remains reddened and excoriated. Spine incision steri-strips\n d/I, area remains pink without drainage. Mepilex to coccyx c/d/i.\n Action:\n Nystatin powder and protective barrier cream applied. T+R q2hr.\n Response:\n Unchanged this shift.\n Plan:\n Cont to monitor skin integrity.\n S&S eval done, + asp on thin liquids. Able to take nectar thick liquids\n and puree. Meds to be crushed in applesauce.\n" }, { "category": "Rehab Services", "chartdate": "2125-10-30 00:00:00.000", "description": "Repeat Bedside Swallowing Evaluation", "row_id": 712146, "text": "TITLE: REPEAT BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 75 y/o female with recent\nadmission with worsening back pain with MRI concerning for\nosteomyelitis of lumbar spine. She underwent a total laminectomy\nof L2-L4 , fusion of L2-L4 and segmental instrumentation of L2-L4\nwith implantation of autografts. Course was complicated by\nhypotension and decreased urine output. She was d/c'd to \n rehab on 12/4but readmitted to PSH on increased HR and low\nBP and she was transferred here on . TLC was placed in\nright groin and pt initially requiring NRB.\nPt is well known to our service from her last admission and was\nd/c'd on nectar thick liquids and soft solids with meds whole in\npuree. Pt requesting thin liquids on admission and we were\nreconsulted. Patient was seen for a bedside swallowing evaluation\non and was recommended for thin liquids and ground solids\n difficulty masticating solids altered MS and dry oral\ncavity. Later that day, patient developed respiratory distress\nand was treated and eventually intubated for spine MR. \nwas extubated this am and we were consulted to return to repeat\nthe bedside swallowing evaluation.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed in the MICU.\nCognition, language, speech, voice:\nPatient was awake, fatigued, a little shaky, and requesting\nwater. Patient was able to follow most basic commands. Speech was\nfluent and voice wfl.\nTeeth: bottom teeth in fair condition - upper dentures in place\nSecretions: extremely dry oral mucosa, but no dried secretions\nORAL MOTOR EXAM:\nSymmetrical facial appearance with adequate lip seal and buccal\ntone. Tongue was at midline with mildly reduced ROM. Palatal\nelevation was symmetrical and weak. Absent gag upon yankauer\nsuctioning.\nSWALLOWING ASSESSMENT:\nThe pt was seen with ice chips, thin liquids (tsp, straw,\nconsecutive), nectar thick liquids, puree, and ground solids.\nOral phase was remarkable for reduced mastication of ground solid\nwith mild oral residue remaining. Laryngeal elevation felt\nreduced to palpation. Mild wet vocal quality, throat clearing,\nand coughing noted intermittently on thin liquids. O2 sats\nremained stable. Patient denied the sensation of food or liquid\nstuck in her throat or going down the wrong way.\nSUMMARY / IMPRESSION:\nMs. appeared with s/sx of aspiration on thin liquids as\nevidenced by intermittent wet vocal quality, throat clearing and\ncoughing and reduced mastication for ground solids. Recommend\ninitiating a PO diet of nectar thick liquids and puree\nconsistencies at this time with supervision and patient seated\nfully upright. If there are concerns for aspiration on this diet,\nplease keep her NPO. We will continue to follow.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 5.\nRECOMMENDATIONS:\n1. PO diet of nectar thick liquids and puree.\n2. Continue supervision for all PO intake. Patient seated fully\nupright for all POs.\n3. Meds crushed with apple sauce.\n4. TID oral care.\n5. If there are concerns for aspiration on this diet, please keep\nher NPO.\n6. We will f/u later in the week to advance her as able.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 1445-1500\nTotal time: 60 minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 711862, "text": "Chief Complaint: hypotension\n HPI:\n 75 yo female with a history of atrial fibrillation, vertebral\n osteomyelitis, and c. diff who presents to OSH with respiratory\n distress. At rehab, O2 sats were noted to be in low 80s on RA. She\n was given metoprolol 50mg PO, lasix 80mg IV and noted to be hypotenisve\n with BP 96/49. She was placed on BiPAP for respiratory distress. At\n OSH, CTA of chest was neg for PE, but showed bilat effusions with\n atelectasis. At OSH, she was placed on dopamine for SBPs 70-80s. They\n did not give her IVF.\n .\n In the ED, initial vs were: 96.1 80/palp 90 14 95% on NRB. Right\n groin line placed because she was unable to lay flat. She received\n zosyn in the ED. She is on on vanco & flagyl for osteomyelitis and C.\n diff. She received 1L IVF with improvement in her BP to 110s. Her\n current vital signs are 102 96/75 32 90% on 5L.\n .\n On the floor, the patient reports some transient difficulty breathing\n that has since resolved. She reports her heart was racing at the\n time. She is anxious and somewhat confused and not able to provide\n further history. She reports lack of appetite and poor PO intake, but\n denies nausea, vomiting and abdominal pain. She reports her diarrhea\n is better; she is having 2 formed BMs/day. She denies fevers/chills,\n cough. She denies orthopnea but appears more SOB lying flat. She\n occasionally wakes up SOB. She feels her LE edema is improved.\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Metronidazole - 06:56 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Medications:\n 1. Amitriptyline 25 mg PO HS\n 2. Trifluoperazine 2 mg PO DAILY\n 3. Ranitidine HCl 150 mg PO BID\n 4. Simvastatin 40 mg PO DAILY\n 5. Oxycodone 5 mg 1-2 Tablets PO Q4H PRN\n 6. Senna 8.6 mg PO BID PRN\n 7. Ferrous Sulfate 325 mg PO DAILY\n 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Topical DAILY\n 9. Miconazole Nitrate 2 % 1 Appl Topical \n 10. Acetaminophen 500 mg Tablet Sig: Two (2) PO Q6H\n 11. Lorazepam 0.5 mg PO Q6H\n 12. Bisacodyl 10 mg 1 PR PRN\n 13. Phenol 1.4 % Aerosol, Spray 1 Spray Mucous membrane Q6H (every 6\n hours) as needed for sore throat.\n 14. Aspirin 81 mg PO DAILY\n 15. NPH Insulin Human Recomb 100 unit/mL Suspension Sig:\n Fourteen (14) units Subcutaneous at bedtime.\n 16. Insulin- Sliding Scale\n Continue insulin sliding scale per attached document\n 17. Vancomycin 1250mg IV q24hr x 8 weeks\n 18. Flagyl 500mg IV q8hr for duration of vancomycin treatment plus\n an additional 5 days\n 19. Furosemide 40 mg PO DAILY\n 20. Heparin (Porcine) 5,000 unit/mL TID\n 21. Metoprolol Tartrate 50 mg PO BID\n Past medical history:\n Family history:\n Social History:\n # Vertebral osteomyelitis -, s/p a total laminectomy of L2/L3/L4,\n fusion L2-L4, segmental instrumentation of L2-L4, and implantation of\n autograft was performed. Osteo thought to be complication from steroid\n injection for spinal stenosis\n # Atrial fibrillation s/p ablation, not on coumadin\n # Iron-deficiency anemia\n # Gastritis per EGD, \n # Insulin-dependent diabetes mellitus c/b neuropathy, retinopathy\n # Lumbar stenosis, s/p L5-S1 laminectomy (age 40)\n # Hypertension\n # Hyperlipidemia\n # DJD\n # Tremor\n # Steatohepatitis\n # Depression / Anxiety disorder\n PAST SURGICAL HISTORY:\n # Cataract surgery\n # Carpal tunnel release bilaterally\n # Tonsillectomy\n # Appendectomy\n # Cholecystectomy\n Diabetes\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Patient currently in rehab. Typically lives in a house in\n , Mass\n with her husband. She is now retired but formerly worked in\n medical records at Hospital. She denies EtOH, tobacco,\n and other drugs.\n Review of systems: (+) weight loss poor po intake per patient\n (-) Denies fever, chills, night sweats, Denies headache, sinus\n tenderness, rhinorrhea or congestion. Denied cough, shortness of\n breath. Denied chest pain or tightness, palpitations. No recent change\n in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias.\n Flowsheet Data as of 07:02 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 102 (97 - 109) bpm\n BP: 115/83(91) {114/47(67) - 129/83(91)} mmHg\n RR: 30 (25 - 35) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 122 mL\n PO:\n TF:\n IVF:\n 122 mL\n Blood products:\n Total out:\n 0 mL\n 378 mL\n Urine:\n 28 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -256 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General: Alert, oriented x 2 tachypneic to 30, SOB with speaking in\n full sentences. + tremor\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: decreased breath sounds bilat at the bases. no wheezes, rales,\n ronchi\n CV: rapid rate, regular rhythm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, +distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: foley in place\n Ext: + LE bilat. warm, well perfused, 2+ pulses, no clubbing,\n cyanosis. right fem line.\n Back: healing surgical incision midline lumbar back w/o erythema.\n sacral decub stage I.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:2.5 mmol/L\n Fluid analysis / Other labs: pH\n 7.26 pCO2\n 46 pO2\n 47 HCO3\n 22 BaseXS\n -6\n Comments: pO2: No Calls Made - Not Arterial Blood\n Type:Central Venous\n Lactate:2.5\n O2Sat: 74\n \n 03:45a\n -----------------------------------------------------------------------\n ---------\n Color\n Yellow Appear\n Hazy SpecGr 1.010 pH 5.0 Urobil0.2 Bili Neg Leuk Sm BldTr\n NitrNeg Prot30 GluNeg KetNeg RBC0-2 WBC6-10 BactFew YeastRARE\n Epi0-2\n Comments: URINE Yeast: Budding & Hyphae Yeast\n \n 02:46a\n -----------------------------------------------------------------------\n ---------\n Green Top Tube\n Lactate:2.4\n \n 02:44a\n -----------------------------------------------------------------------\n ---------\n Trop-T: 0.03\n Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n 144 109 26 AGap=17\n ---------------< 220\n 3.9 22 1.3\n CK: 31 MB: Notdone\n Ca: 7.8 Mg: 1.3 P: 5.5\n ALT: 11 AP: 203 Tbili: 0.5 Alb:\n AST: 20 LDH: Dbili: TProt:\n : Lip: 32\n Other Blood Chemistry:\n Vanco: 26.3\n MCV 90\n WBC 16.6\n HGB 10.4\n PLT 491\n HCT 33.3\n N:94.7 L:2.7 M:2.4 E:0.1 Bas:0.1\n PT: 17.5 PTT: 46.4 INR: 1.6\n Imaging: Micro: blood cx pending\n .\n Images: CXR with left sided effusion\n CTA chest: bilat effusions, + ascites.\n .\n EKG: ST 103, old anterior infarct. poor R wave progression. TWI in\n laterally seen on OSH EKGs.\n Assessment and Plan\n Assessment and Plan: 75 yo female with a complex past medical history\n who was noted to be in respiratory distress at rehab today and\n subsequently hypotensive.\n .\n # Hypotension/Sepsis - The patient hypotension is concerning for\n sepsis given her elevated WBC, hypothermia and her confusion. CT chest\n at OSH was neg for PNA. U/A mildly positive for infection. Other\n possible sources are her back for recurrent abscess. Wound looks\n good. Patient with low EF concerning for a mixed cardiogenic shock\n picture given her peripheral edema and effusions. Pt denied\n CP/pressure but will r/o MI as cause of sx. BP responded to IVF\n - check blood, urine & stool cx\n - repeat CXR\n - cycle CE and EKGs.\n - Get ECHO in am.\n - broad spectrum antibiotics with vanco, flaygl and zosyn\n - repeat venous lactate.\n - bolus with IVF to keep MAP>60\n .\n # Shortness of breath - Patient's shortness of breath most likely due\n to pulmonary edema and bilat effusions. Her symptoms may have been\n worsened by a rapid heart rhythm given her reported palpitations. No\n e/o PE or PNA on OSH CTA scan.\n - repeat CXR\n - hold on lasix at this time given hypotension\n - abx as above.\n .\n # Osteomyelitis - Wound appears to be healing well. no focal neuro\n deficits at this time\n - will obtain ortho spine consult\n - check vanco level, continue vancomycin.\n - t/c MRI spine.\n .\n # C diff infection - Continue patient's flagyl.\n - check stool culture\n .\n # Atrial Fibrillation/tachycardia - Pt had brief episoded of\n tachycardia to 140s that self terminated. pt was hemodynamically\n stable. unable to get 12 lead\n - if returns check 12 lead\n - hold metoprolol for now\n - pt not anticoagulated\n .\n # chronic systolic heart failure - Pt with peripheral edema but likely\n intravascularly dry. most recent EF 35-40%.\n - will hold metoprolol and lasix for now.\n - repeat echo as above\n .\n # Chronic renal insufficiency - creatinine at 1.3 is close to new\n baseline.\n - avoid nephrotoxins\n - renally dose meds\n .\n # Diabetes Mellitus - NPH 14U qHS with regular insulin sliding scale\n .\n # HTN - hold metoprolol given hypotension.\n .\n # Iron deficiency anemia - Hct 33 at baseline. continue to monitor\n .\n FEN: DM diet, Mechanical soft; Nectar prethickened liquids Soft\n solids. Meds whole with nectar or puree. 1:1 supervision.\n .\n PPX:\n -DVT ppx with heparin SC TID\n -Ranitidine for GI, senna/colace for bowel\n -Pain management with tylenol\n .\n ACCESS: femoral line\n .\n Code: presumed full code.\n .\n Communication: Patient & is HCP\n .\n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:45 AM\n 20 Gauge - 04:57 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n I have seen and examined the patient with the resident and agree\n substantially with the plan as above with the following\n modifications/emphasis:\n 75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema. Abd soft NT ND\n CT scan shows bilateral pleural effusions but near clear pneumonia per\n report. U/A shows 6-10 WBCs.\n Lactate 2.5 WBC 16.6\n Assessment:\n 1) Hypothermia/hypotension (sepsis) - likely sepsis although\n unclear exact source. Urine not overly impressive but could be source,\n pneumonia could be present but not well seen initially because of some\n dehydration. Abscess could have recurred or c diff could have\n recurred. be a cardiogenic component given low EF and cool\n extremities.\n 2) History of recent epidural abscess s/p surgical drainage\n 3) Dyspnea/hypoxia: unclear etiology but could be related to\n underlying infection (pneumonia or a low-grade )\n failure possible\n but patient appears clinically dry at this time and PE was ruled out.\n Will need further data as below to help discern\n Plan:\n 1) Panculture including urine and stool (for dif)\n 2) Broad-spectrum antibiotics with flagyl to cover for c. diff\n 3) IVFs for hypotension and likely underlying sepsis\n 4) ECHO to evaluate heart function and help discern if\n cardiogenic component\n Time spent: 35 minutes\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 09:24 AM ------\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 712143, "text": "Chief Complaint: Hypoxemia and Hypotension\n HPI:\n 75F with PMHx of DM2, NASH, vertebral osteo; presented with hypoxemia\n and hypotension. She has been chronically ill with psoas abscess and\n vertebral osteo requiring laminectomy and fusions. Was being treated\n with vancomycin at rehab when she developed hypoxemia. PE-CT performed\n which was negative and then transferred to for further\n management. Evaluation on CCU service included TTE which demonstrated\n EF 45% and apical hypokinesis, mildly elevated lactate at 2.5. She was\n electively intubated to obtain MRI which demonstrates fluid collection\n surrounding the vertebral hardware.\n 24 Hour Events:\n Following arrival in MICU Green, she received 1L fluid bolus with\n minimal improvement in her UOP. She remained hypotensive with MAP in\n 50s. Was started on levophed with improvement. There was difficulty\n obtaining an arterial line for BP monitoring.\n She was extubated this morning without difficulty.\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:01 AM\n Metronidazole - 05:34 AM\n Vancomycin\n Infusions:\n Norepinephrine - off\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Famotidine (Pepcid) - 11:26 PM\n Other medications:\n Simvastatin\n ASA\n Amitryptiline\n Insulin sliding scale\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 107 (71 - 110) bpm\n BP: 135/49(67) {85/28(41) - 135/99(107)} mmHg\n RR: 24 (13 - 35) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 3,244 mL\n 397 mL\n PO:\n TF:\n IVF:\n 3,244 mL\n 397 mL\n Blood products:\n Total out:\n 583 mL\n 145 mL\n Urine:\n 233 mL\n 145 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,661 mL\n 252 mL\n Respiratory support\n O2 Delivery Device: 2L NC\n SpO2 94%\n ABG: 7.37/40/95./21/-1\n Physical Examination\n Gen: Awake, alert, oriented to place/time\n Chest: Clear anterior; diminished left base\n CV: RRR\n Abd: s/nt/mildly distended\n Ext:anasarca\n Labs / Radiology\n 9.1 g/dL\n 485 K/uL\n 179 mg/dL\n 1.7 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 34 mg/dL\n 114 mEq/L\n 145 mEq/L\n 29.2 %\n 12.8 K/uL\n [image002.jpg]\n 11:42 AM\n 01:56 PM\n 03:13 AM\n 04:55 AM\n WBC\n 12.8\n Hct\n 34.1\n 29.2\n Plt\n 485\n Cr\n 1.6\n 1.7\n TropT\n 0.03\n TCO2\n 22\n 24\n Glucose\n 216\n 179\n Other labs: CK / CKMB / Troponin-T:35//0.03, ALT / AST:, Alk Phos\n / T Bili:163/0.4, Differential-Neuts:89.0 %, Lymph:6.7 %, Mono:4.2 %,\n Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:220 IU/L,\n Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:4.6 mg/dL\n Abd CT (report from OSH): cirrhosis, ascites; bilateral pleural\n effusions\n CXR: left sided effusion, atelectasis at left base\n Assessment and Plan\n 75yoF DM2, cirrhosis, with history of osteomyelitis and psoas abscess;\n here with hypoxemia and hypotension.\n 1. Shock: Suspicion was septic shock given elevated lactate and\n potential sources include her known osteomyelitis, SBP (unlikely given\n 26 wbc on dx para); no clear evidence of PNA or UTI. Off pressors\n currently.\n - Continue broad ABX with vancomycin (osteo), zosyn (empiric coverage\n for sepsis, awaiting cultures), flagyl (known cdiff).\n - Await culture data\n - Paracentesis (diagnostic and therapeutic)\n done, diff pending\n - No current indication for arterial BP monitoring\n - Will discuss MRI findings with ortho\n 2. Hypoxemia: Possible pulmonary edema as well as pleural effusions.\n Was intubated only for MRI, now extubated.\n - Large volume paracentesis today\n - Wean FiO2 as tolerated\n 3. Renal Failure: Baseline Cr 0.6; increased since admission\n - urine lytes/sediment; not remarkably responsive to fluids\n - Will get SPA after paracentesis\n ATRIAL FIBRILLATION (AFIB)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE I\n IMPAIRED SKIN INTEGRITY\n ICU Care\n Nutrition: Speech and swallow consult\n Glycemic Control: Insulin sliding scale\n Lines:\n Multi Lumen - 04:45 AM\n 20 Gauge - 04:57 AM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: Famotidine\n VAP: No longer intubated\n Communication: Patient updated during rounds\n Code status: Full code\n Disposition : Just taken off pressors, monitor in ICU this morning, and\n consider transfer to floor later today if stable hemodynamics.\n Total time spent: 35 minutes CCT\n" }, { "category": "Respiratory ", "chartdate": "2125-10-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 711956, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ccu\n Reason: hypercarbic; Comments: placed on NIV with limited improvement\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient with PMHX renal and spine surgery brought to CCU with severe\n hypercarbia PH 7.14 Pac02 71. Patient placed on NIV with mild\n improvement then intubated with # 7.5 ETT taped @ 21 cm. On A/C\n 500*14-60%-5p.\n" }, { "category": "Physician ", "chartdate": "2125-10-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 711839, "text": "Chief Complaint: hypotension\n HPI:\n 75 yo female with a history of atrial fibrillation, vertebral\n osteomyelitis, and c. diff who presents to OSH with respiratory\n distress. At rehab, O2 sats were noted to be in low 80s on RA. She\n was given metoprolol 50mg PO, lasix 80mg IV and noted to be hypotenisve\n with BP 96/49. She was placed on BiPAP for respiratory distress. At\n OSH, CTA of chest was neg for PE, but showed bilat effusions with\n atelectasis. At OSH, she was placed on dopamine for SBPs 70-80s. They\n did not give her IVF.\n .\n In the ED, initial vs were: 96.1 80/palp 90 14 95% on NRB. Right\n groin line placed because she was unable to lay flat. She received\n zosyn in the ED. She is on on vanco & flagyl for osteomyelitis and C.\n diff. She received 1L IVF with improvement in her BP to 110s. Her\n current vital signs are 102 96/75 32 90% on 5L.\n .\n On the floor, the patient reports some transient difficulty breathing\n that has since resolved. She reports her heart was racing at the\n time. She is anxious and somewhat confused and not able to provide\n further history. She reports lack of appetite and poor PO intake, but\n denies nausea, vomiting and abdominal pain. She reports her diarrhea\n is better; she is having 2 formed BMs/day. She denies fevers/chills,\n cough. She denies orthopnea but appears more SOB lying flat. She\n occasionally wakes up SOB. She feels her LE edema is improved.\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Metronidazole - 06:56 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Medications:\n 1. Amitriptyline 25 mg PO HS\n 2. Trifluoperazine 2 mg PO DAILY\n 3. Ranitidine HCl 150 mg PO BID\n 4. Simvastatin 40 mg PO DAILY\n 5. Oxycodone 5 mg 1-2 Tablets PO Q4H PRN\n 6. Senna 8.6 mg PO BID PRN\n 7. Ferrous Sulfate 325 mg PO DAILY\n 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Topical DAILY\n 9. Miconazole Nitrate 2 % 1 Appl Topical \n 10. Acetaminophen 500 mg Tablet Sig: Two (2) PO Q6H\n 11. Lorazepam 0.5 mg PO Q6H\n 12. Bisacodyl 10 mg 1 PR PRN\n 13. Phenol 1.4 % Aerosol, Spray 1 Spray Mucous membrane Q6H (every 6\n hours) as needed for sore throat.\n 14. Aspirin 81 mg PO DAILY\n 15. NPH Insulin Human Recomb 100 unit/mL Suspension Sig:\n Fourteen (14) units Subcutaneous at bedtime.\n 16. Insulin- Sliding Scale\n Continue insulin sliding scale per attached document\n 17. Vancomycin 1250mg IV q24hr x 8 weeks\n 18. Flagyl 500mg IV q8hr for duration of vancomycin treatment plus\n an additional 5 days\n 19. Furosemide 40 mg PO DAILY\n 20. Heparin (Porcine) 5,000 unit/mL TID\n 21. Metoprolol Tartrate 50 mg PO BID\n Past medical history:\n Family history:\n Social History:\n # Vertebral osteomyelitis -, s/p a total laminectomy of L2/L3/L4,\n fusion L2-L4, segmental instrumentation of L2-L4, and implantation of\n autograft was performed. Osteo thought to be complication from steroid\n injection for spinal stenosis\n # Atrial fibrillation s/p ablation, not on coumadin\n # Iron-deficiency anemia\n # Gastritis per EGD, \n # Insulin-dependent diabetes mellitus c/b neuropathy, retinopathy\n # Lumbar stenosis, s/p L5-S1 laminectomy (age 40)\n # Hypertension\n # Hyperlipidemia\n # DJD\n # Tremor\n # Steatohepatitis\n # Depression / Anxiety disorder\n PAST SURGICAL HISTORY:\n # Cataract surgery\n # Carpal tunnel release bilaterally\n # Tonsillectomy\n # Appendectomy\n # Cholecystectomy\n Diabetes\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Patient currently in rehab. Typically lives in a house in\n , Mass\n with her husband. She is now retired but formerly worked in\n medical records at Hospital. She denies EtOH, tobacco,\n and other drugs.\n Review of systems: (+) weight loss poor po intake per patient\n (-) Denies fever, chills, night sweats, Denies headache, sinus\n tenderness, rhinorrhea or congestion. Denied cough, shortness of\n breath. Denied chest pain or tightness, palpitations. No recent change\n in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias.\n Flowsheet Data as of 07:02 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 102 (97 - 109) bpm\n BP: 115/83(91) {114/47(67) - 129/83(91)} mmHg\n RR: 30 (25 - 35) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 122 mL\n PO:\n TF:\n IVF:\n 122 mL\n Blood products:\n Total out:\n 0 mL\n 378 mL\n Urine:\n 28 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -256 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General: Alert, oriented x 2 tachypneic to 30, SOB with speaking in\n full sentences. + tremor\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: decreased breath sounds bilat at the bases. no wheezes, rales,\n ronchi\n CV: rapid rate, regular rhythm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, +distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: foley in place\n Ext: + LE bilat. warm, well perfused, 2+ pulses, no clubbing,\n cyanosis. right fem line.\n Back: healing surgical incision midline lumbar back w/o erythema.\n sacral decub stage I.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:2.5 mmol/L\n Fluid analysis / Other labs: pH\n 7.26 pCO2\n 46 pO2\n 47 HCO3\n 22 BaseXS\n -6\n Comments: pO2: No Calls Made - Not Arterial Blood\n Type:Central Venous\n Lactate:2.5\n O2Sat: 74\n \n 03:45a\n -----------------------------------------------------------------------\n ---------\n Color\n Yellow Appear\n Hazy SpecGr 1.010 pH 5.0 Urobil0.2 Bili Neg Leuk Sm BldTr\n NitrNeg Prot30 GluNeg KetNeg RBC0-2 WBC6-10 BactFew YeastRARE\n Epi0-2\n Comments: URINE Yeast: Budding & Hyphae Yeast\n \n 02:46a\n -----------------------------------------------------------------------\n ---------\n Green Top Tube\n Lactate:2.4\n \n 02:44a\n -----------------------------------------------------------------------\n ---------\n Trop-T: 0.03\n Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n 144 109 26 AGap=17\n ---------------< 220\n 3.9 22 1.3\n CK: 31 MB: Notdone\n Ca: 7.8 Mg: 1.3 P: 5.5\n ALT: 11 AP: 203 Tbili: 0.5 Alb:\n AST: 20 LDH: Dbili: TProt:\n : Lip: 32\n Other Blood Chemistry:\n Vanco: 26.3\n MCV 90\n WBC 16.6\n HGB 10.4\n PLT 491\n HCT 33.3\n N:94.7 L:2.7 M:2.4 E:0.1 Bas:0.1\n PT: 17.5 PTT: 46.4 INR: 1.6\n Imaging: Micro: blood cx pending\n .\n Images: CXR with left sided effusion\n CTA chest: bilat effusions, + ascites.\n .\n EKG: ST 103, old anterior infarct. poor R wave progression. TWI in\n laterally seen on OSH EKGs.\n Assessment and Plan\n Assessment and Plan: 75 yo female with a complex past medical history\n who was noted to be in respiratory distress at rehab today and\n subsequently hypotensive.\n .\n # Hypotension/Sepsis - The patient hypotension is concerning for\n sepsis given her elevated WBC, hypothermia and her confusion. CT chest\n at OSH was neg for PNA. U/A mildly positive for infection. Other\n possible sources are her back for recurrent abscess. Wound looks\n good. Patient with low EF concerning for a mixed cardiogenic shock\n picture given her peripheral edema and effusions. Pt denied\n CP/pressure but will r/o MI as cause of sx. BP responded to IVF\n - check blood, urine & stool cx\n - repeat CXR\n - cycle CE and EKGs.\n - Get ECHO in am.\n - broad spectrum antibiotics with vanco, flaygl and zosyn\n - repeat venous lactate.\n - bolus with IVF to keep MAP>60\n .\n # Shortness of breath - Patient's shortness of breath most likely due\n to pulmonary edema and bilat effusions. Her symptoms may have been\n worsened by a rapid heart rhythm given her reported palpitations. No\n e/o PE or PNA on OSH CTA scan.\n - repeat CXR\n - hold on lasix at this time given hypotension\n - abx as above.\n .\n # Osteomyelitis - Wound appears to be healing well. no focal neuro\n deficits at this time\n - will obtain ortho spine consult\n - check vanco level, continue vancomycin.\n - t/c MRI spine.\n .\n # C diff infection - Continue patient's flagyl.\n - check stool culture\n .\n # Atrial Fibrillation/tachycardia - Pt had brief episoded of\n tachycardia to 140s that self terminated. pt was hemodynamically\n stable. unable to get 12 lead\n - if returns check 12 lead\n - hold metoprolol for now\n - pt not anticoagulated\n .\n # chronic systolic heart failure - Pt with peripheral edema but likely\n intravascularly dry. most recent EF 35-40%.\n - will hold metoprolol and lasix for now.\n - repeat echo as above\n .\n # Chronic renal insufficiency - creatinine at 1.3 is close to new\n baseline.\n - avoid nephrotoxins\n - renally dose meds\n .\n # Diabetes Mellitus - NPH 14U qHS with regular insulin sliding scale\n .\n # HTN - hold metoprolol given hypotension.\n .\n # Iron deficiency anemia - Hct 33 at baseline. continue to monitor\n .\n FEN: DM diet, Mechanical soft; Nectar prethickened liquids Soft\n solids. Meds whole with nectar or puree. 1:1 supervision.\n .\n PPX:\n -DVT ppx with heparin SC TID\n -Ranitidine for GI, senna/colace for bowel\n -Pain management with tylenol\n .\n ACCESS: femoral line\n .\n Code: presumed full code.\n .\n Communication: Patient & is HCP\n .\n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:45 AM\n 20 Gauge - 04:57 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 712075, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Briefly this is a 75 yo F w/ PMH of DMII and recent vertebral\n osteomyelitis w/ ? CONS p/w hypotension and hypoxia. Pt. was initially\n seen in OSH and had CTA chest which was negative for PE. She was\n transferred to and echo showed improved EF but new apical\n hypokinesis. Initially team attempted to diurese her but she did not\n make urine to increasing amounts of furosemide and then it was\n determined that she may be septic. She has remained afebrile while here\n but her WBC was 16. She had an abd U/S which showed a small shrunken\n liver and profuse ascites.\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:01 AM\n Metronidazole - 05:34 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Famotidine (Pepcid) - 11:26 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 95 (71 - 110) bpm\n BP: 103/36(52) {81/28(41) - 123/71(89)} mmHg\n RR: 15 (14 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 3,244 mL\n 367 mL\n PO:\n TF:\n IVF:\n 3,244 mL\n 367 mL\n Blood products:\n Total out:\n 583 mL\n 145 mL\n Urine:\n 233 mL\n 145 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,661 mL\n 222 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 285 (285 - 285) mL\n PS : 14 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 49\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n Compliance: 42.7 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/40/95./21/-1\n Ve: 6.9 L/min\n PaO2 / FiO2: 240\n Physical Examination\n Vitals - T: 95.6 BP: 103/38 HR: 90 RR: 16 02 sat: 100%\n GENERAL: Sedated on vent, responds to stimuli\n HEENT: No icterus\n CARDIAC: RRR, No MRG but distant heart sounds\n LUNG: Clear anteriorly\n ABDOMEN: Moderately distended, soft, NT, BS+\n EXT: 3+ pitting edema to UEs and \n DERM: No rashes\n Labs / Radiology\n Abd U/S Shrunken nodular liver with diffuse ascites consistent\n with the provided history of cirrhosis. The main portal vein is patent.\n A small echogenic nodule abutting the capsule is visualized,\n incompletely characterized on this study. This lesion may be better\n evaluated with multiphasic CT or an MRI of the abdomen if clinically\n indicated.\n .\n EKG: NSR, PRWPTWI V2-V4, low voltage in lateral leads\n .\n CXR: The stomach bubble continues to be distended. There are bilateral\n basal opacities most likely consistent with atelectasis although\n slightly improved on the left accompanied by most likely present small\n bilateral pleural effusions. There is no pneumothorax and the upper\n lungs are clear. There is no evidence of failure.\n 485 K/uL\n 9.1 g/dL\n 179 mg/dL\n 1.7 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 34 mg/dL\n 114 mEq/L\n 145 mEq/L\n 29.2 %\n 12.8 K/uL\n [image002.jpg]\n 11:42 AM\n 01:56 PM\n 03:13 AM\n 04:55 AM\n WBC\n 12.8\n Hct\n 34.1\n 29.2\n Plt\n 485\n Cr\n 1.6\n 1.7\n TropT\n 0.03\n TCO2\n 22\n 24\n Glucose\n 216\n 179\n Other labs: CK / CKMB / Troponin-T:35//0.03, ALT / AST:, Alk Phos\n / T Bili:163/0.4, Differential-Neuts:89.0 %, Lymph:6.7 %, Mono:4.2 %,\n Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:220 IU/L,\n Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 75 yo F w/ DMII, cirrhosis, vertebral osteomyelitis p/w shock/hypoxia\n # Hypoxia: Most likely pleural effusions vs. pulmonary edema. Echo\n was improved but it appears that her liver disease is getting worse and\n could explain her effusions.\n - Consider therapeutic/diagnostic paracentesis\n .\n #Shock: Given echo, does not appear to be cardiogenic though her\n extremities are somewhat cold. Elevated lactate would also suggest\n sepsis along w/ elevated WBC. Lactate trended back to normal w/ IVFs\n but pt. already massively volume overloaded.\n - follow UOP\n - Norepinephrine to sustain MAP>60\n - Piptazo, vanc, flagyl\n - consider diagnostic para\n - stool for cdiff, f/u blood cultures\n .\n # Diabetes Mellitus - NPH 14U qHS with regular insulin\n sliding scale with good control of her sugars\n .\n # HTN - hold metoprolol given hypotension.\n .\n # Iron deficiency anemia - Hct 33 at baseline. continue to monitor\n .\n FEN: DM diet, Mechanical soft; Nectar prethickened liquids Soft solids.\n Meds whole with nectar or puree. 1:1 supervision.\n .\n PPX:\n -DVT ppx with heparin SC TID\n -Ranitidine for GI, senna/colace for bowel\n -Pain management with tylenol\n .\n ACCESS: femoral line\n .\n Code: presumed full code.\n .\n Communication: Patient & is HCP, son :\n \n .\n Disposition: pending clinical improvement\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 712105, "text": "75 year old female history of osteo, epidural abscess, atrial fib, c.\n dif who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. On examination, she is confused, hypothermic, and relatively\n hypotensive (90s-100s/60s). Lungs are clear and extremities are cool\n with some bilateral pedal edema.\n Sepsis without organ dysfunction\n Assessment:\n Accepted on low dose Levophed @ 0.03 mcg/kg/min.\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 712199, "text": "Sepsis without organ dysfunction\n Assessment:\n Readmitted to MICU 7 on from Hospital with\n increased HR and low BP. Given fluid boluses and started on dopamine\n gtt which has since been weaned off. Pleasant 75 y/o female, awake,\n alert and oriented to self, place, and month. Unclear on the year.\n Denies any pain. Uncomfortable laying flat or on her back. Family at\n bedside. SR/ST on monitor. LS clear, crackles at bases bilat. NC at 3L\n with O2 sats 96%. Abd obese, soft distended. Positive bowel sounds.\n Poor appetite. Passing flatus. Foley in situ, clear yellow urine. Lower\n back skin tear clean and dry, therapeutic ointment applied. Has\n miconazole powder ordered . Aware of transfer to floor.\n Action:\n IV (R groin TLC) running at KVO. Reoriented to year. Turns with\n assistance and placed pillow under back. Encouraged CDB. Needs\n encouragement with taking POs.\nI just want coffee\n per pt. Family\n explaining importance of increasing nutritional intake. Skin care at\n given.\n Response:\n Remains calm, family at bedside. Reports more comfortable after turn.\n Takes meds without issue.\n Plan:\n Wean O2. Increase diet as tolerated. Wean O2. Pulmonary hygiene.\n Education on POC and disease process; emotional support. Transfer to\n floor.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n HYPOTENSION\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 96 kg\n Daily weight:\n Allergies/Reactions:\n Demerol (Oral) (Meperidine Hcl) Nausea/Vomiting, Codeine\n Nausea/Vomiting\n Precautions: Contact for .\n PMH: Anemia, Diabetes\n Insulin, Hypertension, afib s/p ablation, not\n on Coumadin, gastritis per EGD, retinopathy\n lumbar stenosis s/p l5-s1 laminectomy, ^ chol, DJD, tremor,\n steatohepatitis, depression\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:112\n D:40\n Temperature:\n 95.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 60% %\n 24h total in:\n 1,361 mL\n 24h total out:\n 2,457 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 03:13 AM\n Potassium:\n 3.4 mEq/L\n 03:13 AM\n Chloride:\n 114 mEq/L\n 03:13 AM\n CO2:\n 21 mEq/L\n 03:13 AM\n BUN:\n 34 mg/dL\n 03:13 AM\n Creatinine:\n 1.7 mg/dL\n 03:13 AM\n Glucose:\n 179 mg/dL\n 03:13 AM\n Hematocrit:\n 29.2 %\n 03:13 AM\n Finger Stick Glucose:\n 154\n 04:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n R groin TLC, #20 PIV L FA\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7 - 784\n Transferred to: CC7 718\n Date & time of Transfer: PM\n .\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 712200, "text": "Sepsis without organ dysfunction\n Assessment:\n 75 year old female history of osteo, epidural abscess, atrial fib, c.\n diff who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. Awake, alert and oriented to self, place, and month. Unclear on\n the year. Denies any pain. Uncomfortable laying flat or on her back.\n Family at bedside. SR/ST on monitor. LS clear, crackles at bases bilat.\n NC at 3L with O2 sats 96%. Abd obese, soft distended. Positive bowel\n sounds. Poor appetite. Passing flatus. Foley in situ, clear yellow\n urine. Lower back skin tear clean and dry, therapeutic ointment\n applied. Has miconazole powder ordered . Aware of transfer to floor.\n Action:\n IV (R groin TLC) running at KVO. Reoriented to year. Turns with\n assistance and placed pillow under back. Encouraged CDB. Needs\n encouragement with taking POs.\nI just want coffee\n per pt. Family\n explaining importance of increasing nutritional intake. Skin care at\n given.\n Response:\n Remains calm, family at bedside. Reports more comfortable after turn.\n Takes meds without issue.\n Plan:\n Wean O2. Increase diet as tolerated. Wean O2. Pulmonary hygiene.\n Education on POC and disease process; emotional support. Transfer to\n floor.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n HYPOTENSION\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 96 kg\n Daily weight:\n Allergies/Reactions:\n Demerol (Oral) (Meperidine Hcl) Nausea/Vomiting, Codeine\n Nausea/Vomiting\n Precautions: Contact for .\n PMH: Anemia, Diabetes\n Insulin, Hypertension, afib s/p ablation, not\n on Coumadin, gastritis per EGD, retinopathy\n lumbar stenosis s/p l5-s1 laminectomy, ^ chol, DJD, tremor,\n steatohepatitis, depression\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:112\n D:40\n Temperature:\n 95.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 60% %\n 24h total in:\n 1,361 mL\n 24h total out:\n 2,457 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 03:13 AM\n Potassium:\n 3.4 mEq/L\n 03:13 AM\n Chloride:\n 114 mEq/L\n 03:13 AM\n CO2:\n 21 mEq/L\n 03:13 AM\n BUN:\n 34 mg/dL\n 03:13 AM\n Creatinine:\n 1.7 mg/dL\n 03:13 AM\n Glucose:\n 179 mg/dL\n 03:13 AM\n Hematocrit:\n 29.2 %\n 03:13 AM\n Finger Stick Glucose:\n 154\n 04:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n R groin TLC, #20 PIV L FA\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7 - 784\n Transferred to: CC7 718\n Date & time of Transfer: PM\n .\n" }, { "category": "Nursing", "chartdate": "2125-10-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 712201, "text": "Sepsis without organ dysfunction\n Assessment:\n 75 year old female history of osteo, epidural abscess, atrial fib, c.\n diff who presented to outside hospital with shortness of breath and\n then became hypotensive after receiving lasix and metoprolol. She was\n placed on bipap, had a CTA which was negative for PE, and transferred\n to . She was transiently on dopamine. In ED, she was\n hypotensive and received IVFs and Zosyn and improved and sent to the\n ICU. Awake, alert and oriented to self, place, and month. Unclear on\n the year. Denies any pain. Uncomfortable laying flat or on her back.\n Family at bedside. SR/ST on monitor. LS clear, crackles at bases bilat.\n NC at 3L with O2 sats 96%. Abd obese, soft distended. Positive bowel\n sounds. Poor appetite. Passing flatus. Foley in situ, clear yellow\n urine. Lower back skin tear clean and dry, therapeutic ointment\n applied. Has miconazole powder ordered . Aware of transfer to floor.\n Action:\n IV (R groin TLC) running at KVO. Reoriented to year. Turns with\n assistance and placed pillow under back. Encouraged CDB. Paracentesis\n today; took off 2L. Needs encouragement with taking POs.\nI just want\n coffee\n per pt. Family explaining importance of increasing nutritional\n intake. Skin care at given.\n Response:\n Remains calm, family at bedside. Reports more comfortable after turn.\n Reports breathing easier since paracentesis. Aspiration precautions,\n nectar thickened liquid and pureed diet ordered.\n Plan:\n Wean O2. Increase diet as tolerated. Wean O2. Pulmonary hygiene.\n Education on POC and disease process; emotional support. Transfer to\n floor.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n HYPOTENSION\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 96 kg\n Daily weight:\n Allergies/Reactions:\n Demerol (Oral) (Meperidine Hcl) Nausea/Vomiting, Codeine\n Nausea/Vomiting\n Precautions: Contact for .\n PMH: Anemia, Diabetes\n Insulin, Hypertension, afib s/p ablation, not\n on Coumadin, gastritis per EGD, retinopathy\n lumbar stenosis s/p l5-s1 laminectomy, ^ chol, DJD, tremor,\n steatohepatitis, depression\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:112\n D:40\n Temperature:\n 95.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 60% %\n 24h total in:\n 1,361 mL\n 24h total out:\n 2,457 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 03:13 AM\n Potassium:\n 3.4 mEq/L\n 03:13 AM\n Chloride:\n 114 mEq/L\n 03:13 AM\n CO2:\n 21 mEq/L\n 03:13 AM\n BUN:\n 34 mg/dL\n 03:13 AM\n Creatinine:\n 1.7 mg/dL\n 03:13 AM\n Glucose:\n 179 mg/dL\n 03:13 AM\n Hematocrit:\n 29.2 %\n 03:13 AM\n Finger Stick Glucose:\n 154\n 04:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n R groin TLC, #20 PIV L FA\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7 - 784\n Transferred to: CC7 718\n Date & time of Transfer: PM\n .\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 712095, "text": "Chief Complaint: Hypoxemia and Hypotension\n HPI:\n 75F with PMHx of DM2, NASH, vertebral osteo; presented with hypoxemia\n and hypotension. She has been chronically ill with psoas abscess and\n vertebral osteo requiring laminectomy and fusions. Was being treated\n with vancomycin at rehab when she developed hypoxemia. PE-CT performed\n which was negative and then transferred to for further\n management. Evaluation on CCU service included TTE which demonstrated\n EF 45% and apical hypokinesis, mildly elevated lactate at 2.5. She was\n electively intubated to obtain MRI which demonstrates fluid collection\n surrounding the vertebral hardware.\n 24 Hour Events:\n Following arrival in MICU Green, she received 1L fluid bolus with\n minimal improvement in her UOP. She remained hypotensive with MAP in\n 50s. Was started on levophed with improvement. There was difficulty\n obtaining an arterial line for BP monitoring.\n She was extubated this morning without difficulty.\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:01 AM\n Metronidazole - 05:34 AM\n Vancomycin\n Infusions:\n Norepinephrine - off\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Famotidine (Pepcid) - 11:26 PM\n Other medications:\n Simvastatin\n ASA\n Amitryptiline\n Insulin sliding scale\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 107 (71 - 110) bpm\n BP: 135/49(67) {85/28(41) - 135/99(107)} mmHg\n RR: 24 (13 - 35) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 3,244 mL\n 397 mL\n PO:\n TF:\n IVF:\n 3,244 mL\n 397 mL\n Blood products:\n Total out:\n 583 mL\n 145 mL\n Urine:\n 233 mL\n 145 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,661 mL\n 252 mL\n Respiratory support\n O2 Delivery Device: 2L NC\n SpO2 94%\n ABG: 7.37/40/95./21/-1\n Physical Examination\n Gen: Awake, alert, oriented to place/time\n Chest: Clear anterior; diminished left base\n CV: RRR\n Abd: s/nt/mildly distended\n Ext:anasarca\n Labs / Radiology\n 9.1 g/dL\n 485 K/uL\n 179 mg/dL\n 1.7 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 34 mg/dL\n 114 mEq/L\n 145 mEq/L\n 29.2 %\n 12.8 K/uL\n [image002.jpg]\n 11:42 AM\n 01:56 PM\n 03:13 AM\n 04:55 AM\n WBC\n 12.8\n Hct\n 34.1\n 29.2\n Plt\n 485\n Cr\n 1.6\n 1.7\n TropT\n 0.03\n TCO2\n 22\n 24\n Glucose\n 216\n 179\n Other labs: CK / CKMB / Troponin-T:35//0.03, ALT / AST:, Alk Phos\n / T Bili:163/0.4, Differential-Neuts:89.0 %, Lymph:6.7 %, Mono:4.2 %,\n Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:220 IU/L,\n Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:4.6 mg/dL\n Abd CT (report from OSH): cirrhosis, ascites; bilateral pleural\n effusions\n CXR: left sided effusion, atelectasis at left base\n Assessment and Plan\n 75yoF DM2, cirrhosis, with history of osteomyelitis and psoas abscess;\n here with hypoxemia and hypotension.\n 1. Shock: Suspicion was septic shock given elevated lactate and\n potential sources include her known osteomyelitis, SBP; no clear\n evidence of PNA or UTI. Off pressors currently.\n - Continue broad ABX with vancomycin (osteo), zosyn (empiric coverage\n for sepsis, awaiting cultures), flagyl (known cdiff).\n - Await culture data\n - Paracentesis (diagnostic and therapeutic)\n - No current indication for arterial BP monitoring\n - Will discuss MRI findings with ortho\n 2. Hypoxemia: Possible pulmonary edema as well as pleural effusions.\n Was intubated only for MRI, now extubated.\n - Large volume paracentesis today\n - Wean FiO2 as tolerated\n 3. Renal Failure: Baseline Cr 0.6; increased since admission\n - urine lytes/sediment; not remarkably responsive to fluids\n - Will get SPA after paracentesis\n ATRIAL FIBRILLATION (AFIB)\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n HEART FAILURE (CHF), SYSTOLIC, ACUTE ON CHRONIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE I\n IMPAIRED SKIN INTEGRITY\n ICU Care\n Nutrition: Speech and swallow consult\n Glycemic Control: Insulin sliding scale\n Lines:\n Multi Lumen - 04:45 AM\n 20 Gauge - 04:57 AM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: Famotidine\n VAP: No longer intubated\n Communication: Patient updated during rounds\n Code status: Full code\n Disposition : Just taken off pressors, monitor in ICU this morning, and\n consider transfer to floor later today if stable hemodynamics.\n Total time spent: 35minutes\n" }, { "category": "Physician ", "chartdate": "2125-10-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 712103, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Started on levophed after BP did not respond to fluids\n Extubated\n Noted to be coughing while eating ice chips\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Metronidazole - 05:34 AM\n Piperacillin/Tazobactam (Zosyn) - 10:01 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:48 PM\n Famotidine (Pepcid) - 08:52 AM\n Heparin Sodium (Prophylaxis) - 08:52 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.7\nC (96.3\n HR: 97 (71 - 110) bpm\n BP: 125/51(67) {85/28(41) - 137/103(108)} mmHg\n RR: 15 (13 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 3,244 mL\n 605 mL\n PO:\n TF:\n IVF:\n 3,244 mL\n 605 mL\n Blood products:\n Total out:\n 583 mL\n 225 mL\n Urine:\n 233 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,661 mL\n 380 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 285 (285 - 285) mL\n PS : 14 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 49\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n Compliance: 42.7 cmH2O/mL\n SpO2: 100%\n ABG: 7.37/40/95./21/-1\n Ve: 6.9 L/min\n PaO2 / FiO2: 240\n Physical Examination\n Gen: Alert but only oriented to person and place, able to state\n \n HEENT: No icterus\n Heart: RRR, No MRG, distant heart sounds\n Lungs: Diminished breath sounds in the bases bilaterally\n Abd: Obese, + fluid wave, BS+\n Ext: 4+ pitting edema in UEs/ \n Labs / Radiology\n 485 K/uL\n 9.1 g/dL\n 179 mg/dL\n 1.7 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 34 mg/dL\n 114 mEq/L\n 145 mEq/L\n 29.2 %\n 12.8 K/uL\n [image002.jpg]\n 11:42 AM\n 01:56 PM\n 03:13 AM\n 04:55 AM\n WBC\n 12.8\n Hct\n 34.1\n 29.2\n Plt\n 485\n Cr\n 1.6\n 1.7\n TropT\n 0.03\n TCO2\n 22\n 24\n Glucose\n 216\n 179\n Other labs: CK / CKMB / Troponin-T:35//0.03, ALT / AST:, Alk Phos\n / T Bili:163/0.4, Differential-Neuts:89.0 %, Lymph:6.7 %, Mono:4.2 %,\n Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:2.4 g/dL, LDH:220 IU/L,\n Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 75 yo F w/ hypotension/hypoxia s/p laminectomy for lumbar\n osteomyelitis.\n 1. Hypotension: Echo normal, Lactate had been elevated and WBC\n elevated, would most likely be septic. Potential Sources of sepsis\n would include C.diff, SBP and progression of osteomyelitis which ID was\n not convinced was caused by CONS. Also a portion likely due to\n cirrhosis and FTT given recent hospitalization and malnutrition.\n - Diagnostic/therapeutic paracentesis\n - continue pip/tazo, vanc, metronidazole\n - Wean levophed\n - Hold fluids given massive fluid overload\n - repeat stool cdiff\n - f/u blood cultures\n - follow UOP\n 2. Hypoxia: Resolving, now only on 2L NC, most likely due to\n pleural effusions/pulmonary edema.\n - Aggressive diuresis after resolution of sepsis.\n 3. DMII: Currently not taking PO\n - NPH 14 U QHS\n - Hold SSI given NPO\n 4. Cirrhosis: Pt. has a previous diagnosis of NASH, U/S appears\n to be cirrhosis.\n - Hepatology f/u\n - <2g daily acetaminophen\n 5. HTN: Holding antihypertensives given current hypotension\n FEN: Will get s/s consult given intubation and coughing w/\n eating then diabetic\n Access: Femoral line, unable to obtain Aline\n Code: Full\n Communication: (daughter) ()\n Dispo: Floor pending wean from levophed and no increase in O2\n requirement\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711835, "text": "75yo recently admitted () with worsening back pain MRI concerning\n for osteomyelieitis of lumbar spine. Underwent a total laminecomy of\n l2-l4, fusion of l2-l4 segmental instrumentation of L2-L4 and\n implantation of autografts. In OR cultures had 1+ poly on gram stain\n of tissue and cx were NGSF. This was c/b hypotension and decreased\n uo. She was D/c'd on to Rehab. Admitted to \n with ^ hr and low bp. There they started iv dopamine and transferred\n to for further management,. In ew TLC was placed in R groin. 1\n L ns bolus was given and dopamine was dc'd. She was initially on 100%\n NRB with sats in the upper 90's this has been decreased to 3lnp with\n sats in the mid 90's. Her RR conts to be elevated in the 30's. Bp\n 100-120's after bolus with hr 90-100's sr/st. She is being transferred\n to MICU covered by CCU team for further management.\n Arrived CCU tachynpeic but with sats in the upper 90\ns on 3lnp. Temp\n 98.0 rectally, with extrems cool to touch. Rec\nd dose zosyn in ew,\n rec\ning flagyl at 6am, awaiting vanco level prior to giving dose. Hr\n initially 90- with occ pac, had episode of svt rate in the\n 130\ns with bp in the 90\ns but arm above chest and refusing to go on\n back, rhythm broke prior to ekg. She is to receive additional 500cc\n NS. Lungs with diminished aeration in bases otherwise clear. O2\n remains at 3lnp difficult at times to get sat due to poor circulation\n in extrems. Abd softly distended (+) bowel sounds. No bm but being\n tx\nd for previous c-diff, therefore on precautions. Foley drng small\n amts of yellow urine. She is slightly confused, stating that she went\n xmas shopping and that she has eaten breakfast. She is aware that she\n is in the hospital and that it is\nxmas time\n but unsure of year. Her\n coccyx has a stage 1 decub and a mepilex was applied. She has 2\n incision sites, L flank and spine area. She has multiple skin tears\n on\n" }, { "category": "Nursing", "chartdate": "2125-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711836, "text": "75yo recently admitted () with worsening back pain MRI concerning\n for osteomyelieitis of lumbar spine. Underwent a total laminecomy of\n l2-l4, fusion of l2-l4 segmental instrumentation of L2-L4 and\n implantation of autografts. In OR cultures had 1+ poly on gram stain\n of tissue and cx were NGSF. This was c/b hypotension and decreased\n uo. She was D/c'd on to Rehab. Admitted to \n with ^ hr and low bp. There they started iv dopamine and transferred\n to for further management,. In ew TLC was placed in R groin. 1\n L ns bolus was given and dopamine was dc'd. She was initially on 100%\n NRB with sats in the upper 90's this has been decreased to 3lnp with\n sats in the mid 90's. Her RR conts to be elevated in the 30's. Bp\n 100-120's after bolus with hr 90-100's sr/st. She is being transferred\n to MICU covered by CCU team for further management.\n Arrived CCU tachynpeic but with sats in the upper 90\ns on 3lnp. Temp\n 98.0 rectally, with extrems cool to touch. Rec\nd dose zosyn in ew,\n rec\ning flagyl at 6am, awaiting vanco level prior to giving dose. Hr\n initially 90- with occ pac, had episode of svt rate in the\n 130\ns with bp in the 90\ns but arm above chest and refusing to go on\n back, rhythm broke prior to ekg. She is to receive additional 500cc\n NS. Lungs with diminished aeration in bases otherwise clear. O2\n remains at 3lnp difficult at times to get sat due to poor circulation\n in extrems. Abd softly distended (+) bowel sounds. No bm but being\n tx\nd for previous c-diff, therefore on precautions. Foley drng small\n amts of yellow urine. She is slightly confused, stating that she went\n xmas shopping and that she has eaten breakfast. She is aware that she\n is in the hospital and that it is\nxmas time\n but unsure of year. Her\n coccyx has a stage 1 decub and a mepilex was applied. She has 2\n incision sites, L flank and spine area. She has multiple skin tears\n on. MD called son and he is aware that she is here. He is\n stating that she if a full code though she is stating that she does not\n wish to be intubated or have cpr. Health Care proxy is daughter .\n" }, { "category": "ECG", "chartdate": "2125-10-29 00:00:00.000", "description": "Report", "row_id": 161917, "text": "Compared to the previous tracing sinus tachycardia has given way to normal\nsinus rhythm with rate 94. Q-T interval prolongation is more pronounced and\nanterolateral T wave abnormalities consistent with myocardial ischemia, drug\neffect or primary central nervous system process are also more exaggerated.\nAgain, there is the suggestion not only of anteroseptal myocardial infarction\nof indeterminate age but also inferior myocardial infarction of indeterminate\nage.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2125-10-29 00:00:00.000", "description": "Report", "row_id": 161918, "text": "Sinus tachycardia, rate 103. Possible/probable anterior myocardial infarction\nof indeterminate age. Generalized non-specific repolarization abnormalities.\nQ-T interval prolongation. Compared to the previous tracing of the\nfrontal plane axis is more rightward. Therefore, inferior myocardial\ninfarction of indeterminate age cannot be diagnosed. Also, atrial ectopy is\nabsent, Q-T interval prolongation is new, and anterolateral repolarization\nabnormalities consistent with inferior myocardial ischemia are new as well.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2125-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1111073, "text": " 8:21 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: effusions & edema\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with tachypnea and SOB\n REASON FOR THIS EXAMINATION:\n effusions & edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: 75-year-old female with tachycardia and shortness of breath.\n\n COMPARISON: Multiple chest radiographs with the most recent from . Chest Ct from .\n\n SINGLE FRONTAL VIEW OF THE CHEST: Dense retrocardiac opacity remains stable.\n The right lung and left upper lung are clear. There is no evidence of\n congestive heart failure or pneumothorax. Aorta is calcified and tortuous.\n Heart is enlarged. Degenerative changes of the spine are noted.\n\n IMPRESSION: Stable retrocardiac opacity compatible with left moderate-sized\n pleural effusion with left lower lobe collapse as correlated with prior CT\n from .\n\n\n" }, { "category": "Radiology", "chartdate": "2125-10-31 00:00:00.000", "description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE", "row_id": 1111471, "text": " 1:24 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC line STAT. thank you.\n Admitting Diagnosis: HYPOTENSION\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with osteomyelitis. Needs PICC line for antibiotics. Going to\n rehab today.\n REASON FOR THIS EXAMINATION:\n please place PICC line STAT. thank you.\n ______________________________________________________________________________\n FINAL REPORT\n PICC PLACEMENT\n\n INDICATION: PICC placement requested for prolonged IV antibiotics for\n osteomyelitis, to discharge to rehab today.\n\n RADIOLOGIST: Dr. , and Dr. , the attending\n radiologist who supervised the entire procedure.\n\n TECHNIQUE: The procedure was explained to the patient. A pre-procedural\n timeout was performed, confirming the patient's identity using 3 patient\n identifiers, as well as the procedure to be performed.\n\n Using sterile technique and 1% lidocaine for local anesthesia, the right\n basilic vein was punctured under direct ultrasound guidance using a\n micropuncture set. Hard copies of ultrasound images were obtained before and\n after establishing intravenous access. A peel-away sheath was then placed\n over a guidewire and a 4 French single-lumen PICC line measuring 44 cm in\n length was then placed through the peel-away sheath under fluoroscopic\n guidance, with its tip positioned in the low SVC. Position of the catheter\n was confirmed by a final fluoroscopic spot film of the chest. The peel-away\n sheath and guidewire were then removed. The catheter was secured to the skin\n using a StatLock, the lumen aspirated, flushed and capped, and a sterile\n dressing applied.\n\n The patient tolerated the procedure well, without immediate complication.\n\n IMPRESSIONS: Successful ultrasound and fluoroscopically guided placement of\n 4-French single-lumen PICC via the right basilic venous approach. Final\n internal length is 44 cm, with the tip positioned in low SVC. The line is\n ready for use.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1111141, "text": " 2:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with hypoxia and altered mental status\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia and altered mental status.\n\n Portable AP chest radiograph was compared to .\n\n The stomach bubble continues to be distended. There are bilateral basal\n opacities most likely consistent with atelectasis although slightly improved\n on the left accompanied by most likely present small bilateral pleural\n effusions. There is no pneumothorax and the upper lungs are clear. There is\n no evidence of failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-10-29 00:00:00.000", "description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT", "row_id": 1111134, "text": " 4:47 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: eval liver and ascites. Please perform doppler studies of t\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with heart failure who presents with worsening abdominal\n ascites and cirrohsis noted on OSH CT chest.\n REASON FOR THIS EXAMINATION:\n eval liver and ascites. Please perform doppler studies of the portal venous\n system.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc MON 6:14 PM\n PFI: Shrunken nodular liver with diffuse ascites consistent with the provided\n history of cirrhosis. The main portal vein is patent. A small echogenic\n nodule abutting the capsule is visualized, incompletely characterized on this\n study. This lesion may be better evaluated with multiphasic CT or an MRI of\n the abdomen if clinically indicated.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Progress of ascites and cirrhosis.\n\n COMPARISON: Limited images from renal ultrasound done on .\n\n FINDINGS: The liver is shrunken and nodular in contour consistent with\n provided history of cirrhosis. There is a small capsule-abutting echogenic\n nodule seen in the right lobe measuring ~8x4 mm. There is no other evidence\n of intrahepatic mass and no intrahepatic biliary ductal dilation. The main\n portal vein is patent with normal hepatopetal flow. The patient is status\n post cholecystectomy. The common bile duct measures 4 mm. Note is made of a\n moderate amount of ascites throughout the abdomen.\n\n IMPRESSION: Shrunken nodular liver with diffuse ascites consistent with the\n provided history of cirrhosis. The main portal vein is patent. A small\n echogenic nodule abutting the capsule is visualized, incompletely\n characterized on this study. This lesion may be better evaluated with\n multiphasic CT or an MRI of the abdomen if clinically indicated.\n\n" }, { "category": "Radiology", "chartdate": "2125-10-29 00:00:00.000", "description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT", "row_id": 1111135, "text": ", R. MED CCU 4:47 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: eval liver and ascites. Please perform doppler studies of t\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with heart failure who presents with worsening abdominal\n ascites and cirrohsis noted on OSH CT chest.\n REASON FOR THIS EXAMINATION:\n eval liver and ascites. Please perform doppler studies of the portal venous\n system.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Shrunken nodular liver with diffuse ascites consistent with the provided\n history of cirrhosis. The main portal vein is patent. A small echogenic\n nodule abutting the capsule is visualized, incompletely characterized on this\n study. This lesion may be better evaluated with multiphasic CT or an MRI of\n the abdomen if clinically indicated.\n\n" }, { "category": "Radiology", "chartdate": "2125-10-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1111045, "text": " 2:43 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? pulm path, central line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with hypotension. New R groin line\n REASON FOR THIS EXAMINATION:\n ? pulm path, central line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with hypotension and new right groin line.\n\n COMPARISON: . Chest CT obtained approximately 4 hours\n earlier at Hospital.\n\n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT 2:45 A.M.: No central venous\n catheter is identified in the region of the chest or upper abdomen. Lung\n volumes are low. There is dense retrocardiac opacity which corresponds to a\n moderate left pleural effusion with atelectasis as seen on the earlier OSH\n chest CT. The right lung and left upper lung are clear without consolidation.\n There is no right pleural effusion. Pulmonary vascularity is normal. Dense\n aortic arch calcifications are again noted. The heart remains enlarged.\n Spine fixation hardware is incompletely visualized.\n\n IMPRESSION: No central venous catheter visualized in the region of the chest\n or upper abdomen. Dense retrocardiac opacity, characterized on recent chest\n CT as pleural effusion and atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2125-10-29 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1111178, "text": " 7:21 PM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p intubation\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with atrial fibrillation, vertebral osteomyelitis, and c.\n diff s/p intubation\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n WET READ: RSRc MON 11:50 PM\n ETT terminates 3.5 cm above carina, otherwise unchanged from earlier this\n afternoon. 11 p .\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:33 P.M., \n\n HISTORY: Atrial fibrillation. Vertebral osteomyelitis and C. difficile\n colitis. Intubation.\n\n IMPRESSION: AP chest compared to :\n\n New ET tube in standard placement. Left lower lobe collapse and small left\n pleural effusion remain. Right lower lobe atelectasis is less severe and\n slightly improved. Upper lungs clear. Heart size top normal. Mediastinal\n vasculature engorged, due in part to supine positioning.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-11-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1111934, "text": " 2:16 PM\n CHEST (PA & LAT) Clip # \n Reason: ? interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with history of L pleural effusion\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Left effusion, assess for interval change.\n\n Two views. Comparison with . There is continued evidence of the\n moderate left pleural effusion and atelectasis or consolidation at the left\n base. The right costophrenic sulcus is blunted, as before. The left\n hemidiaphragm remains elevated. The left heart border is partially obscured.\n The heart is probably enlarged. Mediastinal structures are unchanged. There\n are degenerative changes in the spine. A PICC line remains in place on the\n right.\n\n There is no significant change.\n\n IMPRESSION: No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-11-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1111681, "text": " 4:34 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusion/pulmonary edema\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with lumbar osteomyelitis admitted after having hypoxic and\n hypotensive event at rehab. Resolved. Now tachypneic and developing oxygen\n requirement\n REASON FOR THIS EXAMINATION:\n evaluate for effusion/pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PA AND LATERAL\n\n INDICATION: Lumbar osteomyelitis, admitted after having hypoxic and\n hypotensive event at rehabilitation. Now tachypneic, and developing oxygen\n requirement. Evaluate for effusion or pulmonary edema.\n\n FINDINGS: The patient's condition required examination in AP view sitting on\n wheelchair and corresponding lateral view. Available for comparison is a next\n preceding supine chest examination of . Significant\n cardiomegaly exists as before. The patient is now extubated. There exists a\n left lower lobe density obliterating the diaphragmatic contour and also\n representing pleural effusion as seen on the corresponding lateral view. The\n right base is free, however, the lateral view discloses a small amount of\n pleural effusion in the right-sided posterior pleural sinus as well. The left\n lower lobe density consists of an atelectasis, but probably also some\n infiltrate as a spontaneous air bronchogram is visible in this area. No other\n significant pulmonary parenchymal abnormalities are identified in the\n accessible areas, the pulmonary vasculature does not demonstrate a congestive\n pattern. In comparison with the next previous chest examination, one can now\n identify a right-sided PICC line which terminates overlying the SVC at the\n level 2 cm below the carina. No pneumothorax has developed.\n\n IMPRESSION: Left lower lobe sizable atelectasis and pleural effusion. No\n acute pulmonary infiltrates. Cardiomegaly as before.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-10-29 00:00:00.000", "description": "LUMBO-SACRAL SPINE (AP & LAT)", "row_id": 1111198, "text": " 7:21 PM\n LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: eval for epidural, proegression of osteo or other acute proc\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with atrial fibrillation, vertebral osteomyelitis, and c.\n diff who presents to OSH with respiratory distress and hypotension\n REASON FOR THIS EXAMINATION:\n eval for epidural, proegression of osteo or other acute process\n ______________________________________________________________________________\n WET READ: RSRc MON 8:44 PM\n L2 - L4 fusion and grade II anterolisthesis L4 on L5 unchanged. Post-surgical\n change, gas-filled colon, right femoral line. 8:40 p \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of vertebral osteomyelitis, evaluate for progression of\n osteomyelitis.\n\n LUMBAR SPINE, TWO VIEWS: There are five non-rib-bearing vertebral bodies.\n There is probable diffuse osteopenia. The patient is status post anterior-\n posterior fusion, with intervertebral fusion device at L2/3, at the site of a\n presumed vertebrectomy. There is also a left-sided vertical rod with screws\n extending into the L2 and L3 vertebral bodies. In addition, there are\n bilateral pedicle screws at L2, L3 and L4, which are new compared with\n . There is grade 2 anterolisthesis of L4 on L5 with marked disc space\n narrowing and vascular calcification and scattered surgical clips noted. Right\n femoral line noted. Sacrum obscured by overlying bowel gas. Posterior\n elements obscured by overlying materials.\n\n IMPRESSION: Status post apparent vertebrectomy and fusion at L2/3 with\n interval bilateral pedicle screw fixation at L2 through L4. Stable grade 2\n anterolisthesis and disc space narrowing at L4/5. Allowing for the\n vertebrectomy site, no aggressive osteolysis is identified.\n\n" }, { "category": "Radiology", "chartdate": "2125-10-29 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 1111174, "text": " 5:19 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: eval for epidural, proegression of osteo or other acute proc\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with atrial fibrillation, vertebral osteomyelitis, and c.\n diff who presents to OSH with respiratory distress and hypotension\n REASON FOR THIS EXAMINATION:\n eval for epidural, proegression of osteo or other acute process\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: CXWc TUE 5:50 AM\n Large fluid collection in the posterior soft tissues surrounding the fixation\n hardware. Difficult to determine whether post-surgical collection vs.\n abscess. No collection within the spinal canal. Extensive hardware artifact\n limits assessment.\n ______________________________________________________________________________\n FINAL REPORT\n MRI LUMBAR SPINE WITHOUT CONTRAST DATED :\n\n CLINICAL HISTORY: 75-year-old woman with atrial fibrillation, vertebral\n osteomyelitis and C. diff who presents to outside hospital with respiratory\n distress and hypotension, having recently been discharged from \n after surgery for vertebral osteomyelitis.\n\n TECHNIQUE: MRI of the lumbar spine was performed without the use of\n intravenous contrast. Postcontrast imaging was not obtained as the patient\n has a decreased estimated glomerular filtration rate.\n\n COMPARISONS: MRI of the lumbar spine dated .\n\n FINDINGS: The patient is status post L4 and L5 laminectomies. Since the prior\n examination, there are new postoperative changes, status post laminectomy at\n L2 and L3 with posterior fusion from L2 through L4 bilaterally. There is also\n a spacer in place in the L2-3 region with residual portions of the superior\n aspect of L2 and the inferior aspect of L3. Left sided screw fixation is also\n noted. The hardware results in suscepbitility artifact.\n\n There is a fluid collection related to the dorsal soft tissues overlying the\n thecal sac, related to the fixation rods.\n\n There is no definite evidence of an epidural collection, although evaluation\n is suboptimal given the susceptibility artifact related to the surgical\n hardware and patient motion.\n\n Additionally, there is fluid layering in the retroperitoneum overlying the\n left psoas muscle, which has a different configuration than on the prior\n examination. Because of the left sided nature of the findings, this may be\n related to postsurgical changes given the left sided fixation.\n (Over)\n\n 5:19 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: eval for epidural, proegression of osteo or other acute proc\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The grade 2 anterolisthesis of L4 on L5 is stable in appearance with endplate\n changes at this level. The neural foramina and thecal sac are grossly stable\n since the prior study, although the evaluation again is suboptimal given the\n susceptibility artifact and patient motion.\n\n IMPRESSION:\n\n 1. Postsurgical changes with fluid collections related to the surgical\n hardware in the dorsal soft tissues, which may be postoperative seromas.\n Underlying infection would be difficult to entirely exclude. Corrleate\n clinically and with labs.\n\n 2. Fluid collection in the left aspect of the retroperitoneum also may be\n postsurgical in nature, although underlying infection in this location would\n also be difficult to exclude.\n\n RECOMMENDATIONS: Postcontrast MRI of the lumbar spine would probably not be\n helpful given the degree of susceptibility artifact in the region of the\n surgical hardware. CT of this region may be helpful to better assess the\n surgical hardware and any enhancement.\n\n" }, { "category": "Radiology", "chartdate": "2125-11-02 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1111759, "text": " 9:06 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: to see if patient can tolerate thin liquid diet\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with lumbar osteomyelitis\n REASON FOR THIS EXAMINATION:\n to see if patient can tolerate thin liquid diet\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lumbar osteomyelitis, respiratory decline.\n\n VIDEO OROPHARYNGEAL SWALLOW: The study was conducted in collaboration with\n speech pathology. Various consistencies of barium was administered by mouth.\n There is deep penetration seen with nectar and thin barium consistencies. No\n aspiration is seen. A cough and swallow is effective at clearing the\n vestibule of penetrated barium. There is a large amount of residual in the\n valleculae with pudding consistencies. A 13-mm barium tablet passes freely\n through the pharynx.\n\n IMPRESSION: Deep penetration with nectar and thin consistency barium. Large\n residual seen with pudding consistency.\n\n Please refer to the detailed report from speech pathology that is available on\n CareWeb.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2147-06-17 00:00:00.000", "description": "Report", "row_id": 1504175, "text": "Nursing Progress Note 0700-1900\nEVENTS: Large amt of blood out of R CT site this am. Recieved pt sitting in approx 1 unit of blood. HCT from 0400 am labs 23.8, down 5pts from last noc. Became tachycardic and hypotensive as this shift started, BP into the 80's. Gave 2 units FFP. Surgery here, attending placed several more sutures around CT site w/ resolution of external blood loss. Pt continues to have significant amt of blody fluid out of CT. Approx 450cc this shift. HCT check at 1300 was 28, given additional 1 unit PRBC's.\n\nROS:\n\nCV: HR 100-120's this shift. NiBP 80-120's systolic, lower during acute bleeding this am. now generally 95-110. All antihypertensive held. Coags nl. still holding antiplatelets/ anticoagulant medications. Extremities W&D. T max 100.4, trending down.\n\nRESP: O2 sats >95% on 2L NC. LS clear in L lobes, coarse upper R and diminished R base. R CT to 20cm sx, occasional airleak w/ cough. no crepitus. dressing intact.\n\nNEURO: Pt had episode of anxiety/ extreme fright this am. trying to get OOB, praying to God, etc. Given 5mg Morphine for CP and 2mg IV ativan w/ great affect. Has remained somewhat lethargic through remainder of the day. a bit confused, responds well to reorientation/ support. A&O x2-3. MAE on the bed, no focal neuro defecits. \u0013c/o intermittent R CT site pain, tends to minimize pain.\n\nABD: soft, NT/ND. active bowel sounds. Given general diet tray this evening, did well. tolerating PO's.\n\nGU: Foley placed this am. very minimal u/o throughout the day. given 500cc NS bolus w/ great response.\n\nSKIN: Intact except for R CT site.\n\nSOCIAL: son in to visit. Very supportive and helpful.\n\nPLAN: serial hcts, q6hrs. Goal hct >30. Monitor vitals/ CT out put. monitor for safety in light of intermittent confusion. Morphine for pain. FULL CODE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-06-18 00:00:00.000", "description": "Report", "row_id": 1504176, "text": "ASSESSMENT AS NOTED\n\nTPA WAS INSTALLED IN CT LAST NIGHT TO DESOLVE THE CLOT AND CT WAS CLAMPED FOR 4H, WHEN UNCLAMPED 1L DARK BLOODY SECRETIONS WAS DRAINED, IT CONTINUES TO DRAIN SAME CONTENT AT RATE 80-90CC/H. CT HAS A LEAK NOW SINCE IT WAS UNCLAMPED. PT DENIES SOB BUT C/O R.CHEST WALL PAIN AND GETTING PAIN CONTROL MEDS, SCHEDULED CXR IN AM, STILL ON 2LNC WITH SO2>98\n\nGOT FFP+PC ONE OF EACH OVERNIGHT, BP STABLE , TACHY LOW 100S, NO FEVER, +PULSES, DENIES NAUSEA, TOLERATES CLEAR LIQ WELL\n\nPT WANTS TO PULL HIS FOLEY OUT AND GETS AGGITATED AT TIMES FROM BLADDER SENSATION AND IT WAS O'K-ED BY TORACIC TEAM TO PULL FOLEY OUT IF NEEDED.\n\nNEURO INTACT,\n\nA:ALTERATION IN PULMONARY FUNCTION\n\nPLAN: MONITOR RESP, CHEST TUBE, ? TRANSFER\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-06-17 00:00:00.000", "description": "Report", "row_id": 1504174, "text": "Nursing Note (0100-0700)\n\nPt is a 74 yr old male who originally came to with 1 day of SOB/CP; cardiac enzyme neg. Lg pleural effusion found; thoracentesis with 1680cc of serous exudate with some improvement of SOB but did not completely re-expand his lung. showed a continued Hct drop despite transfusions. CT showed a hemothorax and thus a CT was placed and 200cc sangenous liquid drained. Transferred to MICU for increased nursing needs and closer monitoring.\n\nNeuro: understands English when spoken slowly. Slept fairly thru night. Med x2 with IVP morphine for CT pain with position changes. Verbalized understanding for his reason for admission.\n\nCV: Hemodynamically stable; held lopressor at 12m for BP <95. Hct 23.9 (down from 28.9); coags improved, INR 1.3. Received a total of 2 Units PRBC since admit. Did receive an additional 2units FFP on arrival to MICU. Has two patent #20 PIV's; access poor. CT resutured by surgery with poor effect; CT dsg reinforced x1 and changed x2 for copious amt sangenous drng--team aware. Cont with serial Hct's Q6hrs.\n\nResp; LS clear; diminished to right lower lobe. CT to right with 220 cc bloodly drng; CT to 20cm suction; no crepitus. Strong cough.\n\nGi/GU: Abd soft, NTND. Complaining of thirst--tol water thru night. Attempting to void in urinal as of this writing.\n\nSocial: Son arrived with pt on unit. Verbalized understanding of father's present state. Full code.\n\nPlan; Serial hct's; reinforce/change CT dsg prn. Surgery following. Cardiology to f/u regarding disconuation of plavix/asa with extensive cardiac hx. Emotional support. BR. Prob need to transfuse PRBC\n" }, { "category": "ECG", "chartdate": "2147-06-15 00:00:00.000", "description": "Report", "row_id": 162047, "text": "Sinus rhythm, rate 91. Since the previous tracing of no ventricular\nectopy is present. The Q-T interval is borderline prolonged. Positional changes\nare seen over the lateral precordium.\n\n" }, { "category": "ECG", "chartdate": "2147-06-13 00:00:00.000", "description": "Report", "row_id": 158403, "text": "Sinus rhythm, rate 79. Since the previous tracing of a rare ventricular\npremature beat is seen. Positional changes are noted over the lateral\nprecordium.\n\n" }, { "category": "ECG", "chartdate": "2147-06-13 00:00:00.000", "description": "Report", "row_id": 158404, "text": "Sinus rhythm\nInferior T wave abnormalities - are nonspecific but cannot exclude ischemia\nConsider also Inferior infarct, age indeterminate\nLeft ventricular hypertrophy by voltage\nClinical correlation is suggested\nSince previous tracing of , ventricular ectopy absent\n\n" }, { "category": "ECG", "chartdate": "2147-06-12 00:00:00.000", "description": "Report", "row_id": 158405, "text": "Sinus rhythm\nVentricular premature complex\nInferior T wave abnormalities - are nonspecific but cannot exclude ischemia\nConsider also inferior infarct, age indeterminate\nLeft ventricular hypertrophy by voltage\nClinical correlation is suggested\nSince previous tracing of , ventricular ectopy\n\n" }, { "category": "Radiology", "chartdate": "2147-06-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 910558, "text": " 6:03 PM\n CHEST (PA & LAT) Clip # \n Reason: eval lung re expansion s/p thoracentesis\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with s/p thoracotomy with effusion\n\n REASON FOR THIS EXAMINATION:\n eval lung re expansion s/p thoracentesis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man status post thoracotomy, evaluate lung\n reexpansion status post thoracentesis.\n\n COMPARISON: CTA of the chest from as well as chest x-ray from\n the same day.\n\n PA AND LATERAL CHEST RADIOGRAPHS: There has been interval decrease in the\n size of the right pleural effusion with associated expansion of the right\n lung. There is a persistent small effusion on the right. There is a\n spiculated right upper lobe lesion as well as volume loss on the right\n elevating the right hilum. A surgical clip is seen adjacent to the trachea.\n Cardiac and mediastinal contours appear stable with a tortuous aorta. The\n left lung appears grossly clear. Again seen are right-sided rib fractures.\n\n IMPRESSION: Improvement in the expansion of the right-sided lung after\n thoracentesis. Persistent small pleural effusion. Spiculated lesion in the\n right upper lobe with associated volume loss. This lesion appears to have\n been seen on prior CTs of the chest. Minimally displaced right rib fractures.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911111, "text": " 3:56 PM\n CHEST (PA & LAT) Clip # \n Reason: to eval for interval chnage in hematoma\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with s/p thoracotomy with effusion\n\n REASON FOR THIS EXAMINATION:\n to eval for interval chnage in hematoma\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post thoracotomy with effusion and hematoma.\n\n CHEST: Comparison is made of the prior chest x-ray from . The right\n chest tube is again seen though position of the tip has changed somewhat.\n Right apical pneumothorax is still probably present though reduced from the\n prior chest x-ray. Some collapse of the right lower lobe is present but the\n focal density is seen on the prior chest x-ray has resolved. Right upper lobe\n infiltrate is still present.\n\n The left lung remains clear. There is no evidence of failure.\n\n IMPRESSION: Right lower lobe collapse. Persistent right upper lobe\n opacification.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910837, "text": " 5:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p R lobectomy with hemothorax s/p chest tube\n REASON FOR THIS EXAMINATION:\n chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old status post right lobectomy with hemothorax and chest\n tube. Evaluate for chest tube placement.\n\n COMPARISON: and CT torso.\n\n UPRIGHT CHEST RADIOGRAPH: Again seen is a right-sided subpulmonic pleural\n effusion. There has been interval placement of a right-sided chest tube which\n appears to be kinked as it courses medially. Fluid is seen overlying the\n major fissure and right lung apex. There is no evidence of pneumothorax. The\n left lung is grossly clear.\n\n IMPRESSION:\n 1. Moderate-sized right pleural effusion.\n 2. No evidence of pneumothorax.\n 3. Interval placement of right-sided chest tube which courses medially and\n appears to be kinked.\n\n" }, { "category": "Radiology", "chartdate": "2147-06-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911231, "text": " 11:33 AM\n CHEST (PA & LAT) Clip # \n Reason: chest tube to water seal-plaese eval for ptx-obtain CXR at 1\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with s/p thoracotomy with effusion\n\n REASON FOR THIS EXAMINATION:\n chest tube to water seal-plaese eval for ptx-obtain CXR at 11:30am\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation after thoracotomy in a patient with chest\n tube on water seal.\n\n PA and lateral upright chest radiograph is compared to a previous film from\n yesterday, .\n\n The right chest tube is again seen in unchanged position. The right apical\n pneumothorax, the right basal pneumothorax and adjacent lung atelectasis, and\n the right suprahilar pneumothorax, all of them containing air-fluid level, are\n grossly unchanged. There is slightly enlarged right pleural effusion which\n might be due to the change of the patient's position. The right upper lobe\n infiltrate is unchanged as well.\n\n The left lung is clear with no evidence of left pleural effusion.\n\n IMPRESSION:\n\n 1. Unchanged three pockets of air most probably loculated pneumothorax.\n\n 2. Unchanged right upper pulmonary effusion.\n\n 3. The right rib fractures are again noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911487, "text": " 10:32 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for reaccum of effusion\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p chest tube placement for hemothorax with successful\n drainage after TPA'ing the tube. CT now d/c\n REASON FOR THIS EXAMINATION:\n please eval for reaccum of effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA/LATERAL CHEST.\n\n INDICATION: Status post right chest tube removal. Evaluate for\n reaccumulation of pleural fluid.\n\n FINDINGS: Compared with at 3:07 p.m., no significant interval change.\n The small loculated hydropneumothoraces at the right apex and right base\n appear grossly stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-14 00:00:00.000", "description": "PERSANTINE MIBI", "row_id": 910401, "text": "PERSANTINE MIBI Clip # \n Reason: PT WITH LUNG CANCER, PRESENTS WITH CHEST PAIN, RULED OUT FOR MI, ? REVERSIBLE DEFECT\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 3.2 mCi Tl-201 Thallous Chloride;\n 20.8 mCi Tc-m Sestamibi;\n HISTORY: 74 year old man with chest pain and lung cancer.\n\n SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB:\n\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n milligram/kilogram/min. Two minutes after the cessation of infusion, Tc-m\n sestamibi was administered IV.\n\n INTERPRETATION:\n Image Protocol: Gated SPECT\n Resting perfusion images were obtained with thallium.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n This study was interpreted using the 17-segment myocardial perfusion model.\n\n The image quality is good.\n\n Left ventricular cavity size is normal.\n\n Stress perfusion images reveal moderate reduction in tracer activity in the\n inferior wall. Rest perfusion images show that this defect is fixed.\n\n Gated images reveal mild hypokinesis of the inferior wall.\n The calculated left ventricular ejection fraction is 42%.\n\n Compared with the study of , the fixed inferior wall perfusion defect is\n new, and the left ventricular ejection fraction has decreased.\n\n IMPRESSION: New moderate and fixed inferior myocardial wall perfusion defect.\n Mild inferior wall hypokinesis. Calculated LVEF 42%.\n\n\n , M.D.\n , M.D. Approved: 4:21 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2147-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910849, "text": " 9:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o Ptx s/p chest tube pullback\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p R lobectomy with hemothorax s/p chest tube\n\n REASON FOR THIS EXAMINATION:\n r/o Ptx s/p chest tube pullback\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right lobectomy with hemothorax status post chest\n tube. Evaluate after chest tube pulled back.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: Since the previous examination, the right-sided chest tube has been\n partially withdrawn, and the kinking at the location of the side hole has now\n resolved. The tip terminates at the right base directed medially. The heart\n size and mediastinal contours appear unchanged. There is persistent large,\n loculated right-sided effusion, previously demonstrated on CT to represent\n hemothorax, with loculations of gas at the right lung apex and right base\n consistent with hemopneumothorax. No left-sided pneumothorax.\n\n IMPRESSION:\n 1. Status post repositioning of right-sided chest tube with decrease in\n kinking.\n 2. Right-sided hemopneumothorax, approximately unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910863, "text": " 1:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?layering hemothorax\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p R lobectomy with hemothorax s/p chest tube w/substantial\n bleeding around chest tube site.\n REASON FOR THIS EXAMINATION:\n ?layering hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right lobectomy with hemothorax and substantial\n bleeding around chest tube site.\n\n COMPARISON: , at 21:10 hours.\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: Right-sided chest tube in unchanged position. Right-sided\n effusion, with largest component in subpulmonic location, consistent with\n known hemothorax, and loculated pneumothorax at the right base and right apex,\n appear unchanged. Heart size and mediastinal contours are stable. The left\n lung remains clear.\n\n IMPRESSION: Unchanged appearance of right hemopneumothorax and right-sided\n chest tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911323, "text": " 7:12 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evaluate lung field for effusion/ptx\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p chest tube placement for hemothorax with successful\n drainage after TPA'ing the tube. CT now to water seal.\n REASON FOR THIS EXAMINATION:\n evaluate for any residual effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate residual effusion, chest tube to waterseal.\n\n COMPARISON: .\n\n FINDINGS: The moderate right hydropneumothorax is not significantly changed\n given differences in position. Multifocal opacities in the right lung are\n unchanged. The left lung is clear, and no left effusions are present. Right\n chest tube remains unchanged in position. The cardiac and mediastinal\n contours are stable. Note of an IVC filter. Multiple right rib fractures\n again identified.\n\n" }, { "category": "Radiology", "chartdate": "2147-06-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911342, "text": " 9:25 AM\n CHEST (PA & LAT) Clip # \n Reason: EVALUATE FOR ANY RESIDUAL EFFUSION\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 74-year-old, assess for residual effusion.\n\n PA and lateral radiograph. Comparison is made to study done one hour earlier.\n\n There has been no significant change in the appearance of the residual small\n right apical pneumothorax, right pleural effusion, or multifocal opacities in\n the right lung. The left lung remains clear.\n\n" }, { "category": "Radiology", "chartdate": "2147-06-12 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 910210, "text": " 10:22 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: H/O BILAT DVT'S\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with hx of dve\n REASON FOR THIS EXAMINATION:\n dvt\n ______________________________________________________________________________\n WET READ: MRSg MON 11:48 AM\n Interval decrease in thrombus within right deep venous system, with persistent\n nonocclusive thrombus in right common femoral vein and greater saphenous vein.\n\n Resolution of left lower extremity DVT with no residual thrombus identified.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of DVT, follow up.\n\n COMPARISON: .\n\n TECHNIQUE: Bilateral lower extremity venous ultrasound.\n\n LOWER EXTREMITY VENOUS ULTRASOUND (BILATERAL):\n\n RIGHT LOWER EXTREMITY: -scale, color, and Doppler images of the right\n common femoral, superficial femoral, and popliteal veins were obtained. Within\n the right common femoral vein, extending to its junction with the right\n greater saphenous vein, there is noncompressible, echogenic thrombus. Color\n flow demonstrates that this is nonocclusive. In comparison with the prior\n ultrasound of , the degree of thrombus burden within the\n right lower extremity deep venous system has decreased, with resolution of\n thrombus within the right superficial femoral vein and deep femoral vein and\n within the popliteal vein. On today's examination, the right superficial\n femoral and popliteal veins demonstrate normal compressibility, color flow,\n and waveforms.\n\n LEFT LOWER EXTREMITY: -scale, color, and Doppler images of the left\n common femoral, superficial femoral, and popliteal veins were obtained. Normal\n flow, compressibility, augmentation, and waveforms are demonstrated. No\n intraluminal thrombus is identified.\n\n IMPRESSION:\n\n 1. Nonocclusive thrombus within the right common femoral vein, extending to\n its junction with the right greater saphenous vein. Since the previous\n examination of , the thrombus within the right superficial\n femoral and popliteal veins have resolved.\n\n 2. No deep venous thrombosis in left common femoral, superficial femoral, or\n popliteal veins. The previously present left popliteal and superficial\n femoral venous thrombus has resolved.\n\n Results were conveyed to the ED dashboard at the time of interpretation.\n (Over)\n\n 10:22 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: H/O BILAT DVT'S\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910952, "text": " 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evalutate lung field effusion progression on Right side\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p R lobectomy with hemothorax s/p chest tube w/substantial\n bleeding around chest tube site.\n REASON FOR THIS EXAMINATION:\n evalutate lung field effusion progression on Right side\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM.\n\n History of right lobectomy and hemothorax. Chest tube placement.\n\n Tube is present in the right lower hemithorax. There is a right pneumothorax\n and a focal area of density at the right lung base. There has been some\n resolution of the right upper lobe opacity, although patchy opacities persist\n in the right upper zone. The left lung is grossly clear allowing for low lung\n volumes.\n\n IMPRESSION: Right pneumothorax and the right lower zone ovoid opacity\n consistent with hematoma. Partial resolution of right upper zone opacities\n with increased aeration in this location.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910206, "text": " 9:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p R lobectomy with CP, SOB\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON \n\n INDICATION: Status post right lobectomy and radiation and chemotherapy for\n lung CA. Chest pain and shortness of breath. Evaluate for infiltrate.\n\n FINDINGS: Compared with and , there has been increase in size\n of the right pleural effusion capping the right apex and volume loss with\n partial collapse of the right upper lung, giving a diffuse haziness in the\n medial right upper lung field.\n\n The left lung is clear. No CHF or left effusion.\n\n IMPRESSION: Increased right pleural effusion and partial collapse of the\n right upper lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910908, "text": " 2:09 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change?\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p R lobectomy with hemothorax s/p chest tube w/substantial\n bleeding around chest tube site.\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of right lobectomy with hemothorax and chest tube placement.\n\n Chest tube is present in the right lower hemithorax. There has been no change\n since the previous film of the same date.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 911401, "text": " 3:12 PM\n CHEST (PA & LAT); -76 BY SAME PHYSICIAN # \n Reason: PLEASE EVAL INTERVAL CHANGE PTX S/P CT D/C\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p chest tube placement for hemothorax with successful\n drainage after TPA'ing the tube. CT now d/c\n REASON FOR THIS EXAMINATION:\n please eval interval change, ptx s/p CT d/c\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, AT 15:07\n\n COMPARISON: at 9:02 a.m.\n\n INDICATION: Chest tube removal.\n\n There has been removal of a right-sided chest tube. A basilar loculated\n hydropneumothorax posteriorly has slightly increased in the interval. There\n is no change in a loculated apical hydropneumothorax. A small anterior\n hydropneumothorax probably unchanged allowing for partial obscuration by the\n overlying arms on the prior study. Right pleural effusion, multifocal\n opacities in the right lung, and postoperative volume loss are without change.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-16 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 910746, "text": " 8:26 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please eval for bleed\n Admitting Diagnosis: CHEST PAIN\n Field of view: 34\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with sob and hx of lung ca. Now s/p thoracentesis and Hct\n drop.\n REASON FOR THIS EXAMINATION:\n please eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCT FRI 11:45 AM\n moderate amount of hemorrhage within the right pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 74-year-old man with shortness of breath and history of lung\n carcinoma, status post thoracentesis and dropping hematocrit.\n\n COMPARISON: .\n\n TECHNIQUE: Multidetector axial images of the chest, abdomen, and pelvis were\n obtained without contrast. Coronal and sagittal reformatted images were\n obtained.\n\n CT CHEST: The heart, pericardium, and great vessels are stable. There is a\n small amount of pericardial fluid. No definite axillary, mediastinal, or\n hilar lymphadenopathy is seen. Again seen is a moderate-to large-sized right\n pleural effusion. There has been interval development of moderate amount of\n high-attenuation fluid within the effusion consistent with hemorrhage. Patchy\n consolidation of the right lung is stable. Hazy patchy opacities are noted in\n the left lung field but no frank consolidation is seen.\n\n CT ABDOMEN: Within the limits of this non-contrast study, the liver,\n gallbladder, pancreas, spleen, adrenal glands, kidneys, stomach, and small\n bowel loops are within normal limits. There is colonic diverticulosis most\n prominent at the hepatic flexure. There is no free air or free fluid. No\n mesenteric or retroperitoneal lymphadenopathy is identified. An IVC filter is\n seen.\n\n CT PELVIS: The bladder is unremarkable. The patient appears to be status\n post prostatectomy. The rectum is unremarkable. There is no free fluid and\n no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: A lytic area is again seen in the L5 vertebral body but\n unchanged from prior examination. Several subacute or chronic rib fractures\n are identified on the right.\n\n IMPRESSION:\n 1. Interval development of a moderate amount of hemorrhage within the right\n pleural effusion.\n (Over)\n\n 8:26 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please eval for bleed\n Admitting Diagnosis: CHEST PAIN\n Field of view: 34\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. No acute intra-abdominal abnormalities identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2147-06-12 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 910213, "text": " 10:27 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: pe?\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with sob and hx of lung ca and lobectomy\n REASON FOR THIS EXAMINATION:\n pe?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MGGb MON 3:17 PM\n No PE. large loculated right pleural effusion, mild CHF.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rule out PE.\n\n COMPARISONS: Chest CT of .\n TECHNIQUE: Axial MDCT images of the chest with 150 cc of nonionic Optiray\n contrast per CTA PE protocol with coronal and sagittal reformatted images.\n\n CTA CHEST WITH IV CONTRAST: The patient is s/p right upper lobectomy and\n extensive mediastinal nodal dissection. There is an extensive loculated\n right-sided pleural effusion with a small amount of associated collapse. The\n aerated right lung is unremarkable. The left lung demonstrates mild diffuse\n ground-glass opacity and septal thickening, consistent with a component of\n volume overload. Mild basilar atelectasis of the left lung. There is focal\n ill-defined consolidation involving the left upper lobe anteriorly and\n medially, likely representing focal atelectasis, though should be followed to\n resolution. The pulmonary arteries enhance normally without filling defect.\n The heart is mildly enlarged. The thoracic aorta is unremarkable. Incidental\n note is made of a large lipoma involving the left paraspinal muscles. The\n largest of the previously seen lymph nodes in the mediastinum have been\n removed. There remain subcentimeter lymph nodes in the prevascular, AP\n window, and pretracheal distributions. Coronary stent involving the left\n circumflex artery. Healing right-sided rib fractures, possibly from prior\n thoracotomy. Bone windows demonstrate no other osseous abnormality. No\n suspicious lytic or blastic lesions are detected.\n\n MULTIPLANAR REFORMATS: Coronal and sagittal reformatted images confirm the\n above findings.\n\n IMPRESSION:\n 1) No pulmonary embolism.\n 2) Large loculated right pleural effusion with a small component of collapse.\n 3) Congestive heart failure/volume overload.\n 4) S/p right upper lobectomy and mediastinal nodal dissection with small\n subcentimeter nodes remaining in the prevascular and pretracheal\n distributions.\n 5) Small ill-defined focus of consolidation in the anteromedial aspect of the\n left upper lobe, most likely atelectasis, though this should be followed to\n resolution.\n (Over)\n\n 10:27 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: pe?\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2193-05-16 00:00:00.000", "description": "Report", "row_id": 81533, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 62\nWeight (lb): 248\nBSA (m2): 2.10 m2\nBP (mm Hg): 116/60\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 11:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Moderately dilated LV cavity. Severe global LV hypokinesis.\nSeverely depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Aortic valve not well seen.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Mild (1+) MR. LV\ninflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left ventricular cavity is moderately dilated. There is severe global\nleft ventricular hypokinesis to akinesis with slight preservation of basal\nlateral wall motion. Overall left ventricular systolic function is severely\ndepressed.\n2. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\n\n" }, { "category": "ECG", "chartdate": "2193-05-16 00:00:00.000", "description": "Report", "row_id": 199055, "text": "Sinus rhythm. First degree A-V heart block. Left axis deviation. Left\nbundle-branch block with ST-T wave changes. Compared to the previous tracing no\nsignificant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2193-05-15 00:00:00.000", "description": "Report", "row_id": 199056, "text": "Sinus rhythm, rate 78. Since the previous tracing of more technical\nartifacts are noted. Positional changes are again seen over the lateral\nprecordium.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2193-05-14 00:00:00.000", "description": "Report", "row_id": 199057, "text": "Sinus rhythm, rate 81. Since the previous tracing of a rare ventricular\npremature beat is noted. Positional changes are seen over the lateral\nprecordium.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2193-05-14 00:00:00.000", "description": "Report", "row_id": 199058, "text": "Sinus rhythm, rate 77. Left bundle-branch block. No previous tracing available\nfor comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2193-05-17 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 911647, "text": " 10:58 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evaluate for RP bleed\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CARDIOMYOPATHY\\CATH\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with severe CHF recently went to cath lab w/ balloon pump\n placement (now removed) whose hct is dropping 43->30\n REASON FOR THIS EXAMINATION:\n evaluate for RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old with severe CHF, recent cath with balloon pump\n placement, dropping hematocrit, evaluate for retroperitoneal hematoma.\n\n COMPARISONS: None.\n TECHNIQUE: Axial MDCT images of the abdomen and pelvis without IV contrast.\n\n CT ABDOMEN WITHOUT IV CONTRAST: Lung bases are clear. Evaluation of the\n abdominal viscera is limited without IV or oral contrast, however with the\n exception of an atrophic right kidney and multiple adjacent surgical clips\n and/or vascular stents, no abnormalities are detected. There are multiple\n small likely exophytic simple cysts of the atrophic native right kidney, which\n are not fully characterized on this study. No evidence of hematoma within the\n abdomen, and specifically no evidence of retroperitoneal hematoma. There is\n nonspecific fat stranding in the subcutaneous tissues of the anterior\n abdominal wall as well as posteriorly behind the paraspinal musculature of\n unclear significance. There is diffuse vascular calcification without\n aneurysmal dilatation.\n\n CT PELVIS WITHOUT IV CONTRAST: No evidence of hematoma in the deep pelvis nor\n the right groin, though there is mild inflammatory stranding in the area of\n the right groin, secondary to prior catheterization. Diffuse sigmoid\n diverticuli without evidence of acute diverticulitis.\n\n BONE WINDOWS: Diffuse degenerative changes without suspicious lesions.\n\n IMPRESSION:\n 1) No evidence of retroperitoneal or groin hematoma.\n 2) Atrophic native right kidney, with multiple likely simple cysts which are\n not fully characterized on this study.\n 3) Diffuse vascular calcification.\n 4) Sigmoid diverticulosis without evidence of diverticulitis.\n 5) Mild stranding in the anterior abdominal subcutaneous tissues as well as\n the subcutaneous tissues posterior to the paraspinal muscles of unclear\n etiology.\n\n (Over)\n\n 10:58 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evaluate for RP bleed\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CARDIOMYOPATHY\\CATH\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2193-05-17 00:00:00.000", "description": "Report", "row_id": 1436995, "text": "CCU Nursing Progress Note 7pm-7am\nS: I don't sleep through the night\n\nO: 66yof tx from osh where she had been admitted on for c/o increasing sob and wheezing. Rx at osh for copd vs ht failure (ef 18%), R/O for MI. Tx to for card intervention. Unable to intervene on subtotal RCA lesion, as was difficult to cross. Proceedure c/b diaphoresis and hypotension with sbp down to 70/ requiring transient Dopa and IABP. Admitted to CCU for further w/o.\n\nCV - HR 60-80 nsr with rare pvc. BP 80-126/40-50. Able to administer via hold parameters, Valsartan 80mg at 11pm and Carvedilol 6.25 at 12:30am. At 2am, BP noted down to 80/, but spontaneously increased over next hour without intervention. Now all po cardiac meds are dc/d. R groin cath site with ecchymotic area. DSD intact. Pulses +3/+2 with good csm. HCT 32.8 at midnight.\n\nResp - ls are clear. No O2 on at present with sats 93-98%. No cough.\n\nGu - OOB to commode q 2hrs for voiding. Urine spec sent\n\nGi - Abd is large and soft with +bs.\n\nEndo - cont Humulog SS insulin.\n\nID- WBC has been slightly elevated 14.6-11.9. Urine culture sent. Attempted BC, but unable to obtain with recent blood draw. Will re attempt with AM labs.\nDosing Hydrocortisone for possible adrenal insufficiency.\n\nA: Cont with hypotension after administration of cardiac meds.\n\nP: Attempt to reintroduce po card meds staggering doses as needed, monitor hcts, check pnd cultures, increase activity, heart failure teaching including exercise, wt control, low sodium diet and meds, keep pt and family informed of plan per multidisiciplinary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2193-05-15 00:00:00.000", "description": "Report", "row_id": 1436991, "text": "CCU NPN 7a-7p\nS: \"I can't wait to be able to sit up...\"\nO: please see carevue for complete assessment data.\nEVENTS: IABP and PA line d/c'd.\nNEURO: A&Ox3, c/o pain r/t IABP pull relieved w/ percoset. Cooperating w/ activity restrictions post sheath pull.\n\nCV: Tolerated IABP wean, see carevue for details. Last SvO2 on 1:2 was 77. PAD 12-15; both IABP and PA line d/c'd @ 1130, hemostasis achieved and pressure held x 45mins. Logroll precautions to be maintained until . R fem site c/d/i, no ooze/hematoma noted. Distal pulses 3+/1+ bilaterally. Hct stable 37. MAP 55-80s, NTG gtt weaned off w/ resumation of home antihypertensive regimen. HR NSR w/ occas PVCs, no sustained ectopy on tele.\n\nRESP: SPO2 >95% on 2L NC, desats slightly when turned on R side. LSCTA, diminished RLL. No cough/sputum.\n\nGI: Obese, abd soft, nontender, nondistended. +BS/-BM/+RF. NPO in am for ? NM study, now tolerating CLs as pt. remains flat. Denies N/V.\n\nGU: foley draining CYU. Cont 40mg PO lasix w/ fluid balance -300cc for 24hrs.\n\nENDO: BG covered w/ HISS as needed. Cont PO prednisone.\n\nID: afebrile. WBC trending down\n\nSKIN: w/d/i, no breakdown noted. Multiple areas of excorriation and yeast infection in skin folds-> nystatin lotion/powder applied. PIV x 2 patent and intact.\n\nSOC: dtrs in to visit, updated on pt condition and POC by CCU team and Dr. .\n\nA: 66yo w/ new cardiomyopathy, EF 18%. HD stable s/p IABP pull post-cath.\nP: As per multidiciplinary rounds cont current med regimen, monitor hemodynamics and R fem site post IABP D/C. Encourage diet and activity after . Cont support to pt and family as needed. Anticipate c/o to step down if pt remains stable. LT plan to manage HF medically and f/u w/ EP in 3months to eval for BiV pacer/ICD.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-05-16 00:00:00.000", "description": "Report", "row_id": 1436992, "text": "66 YR. OLD WOMAN WITH NEW CARDIOMYOPATHY->EF 18%. ADMITTED TO OSH WITH DOE-? COPD FLAIR VS CHF EXACERBATION. R/O MI BY ENZYMES. TRANSFERRED TO FOR CATH->SUBTOTAL RCA LESION. LESION TORTUOUS & DIFFICULT TO CROSS, & AFTER MANY ATTEMPTS, PT DIAPHORETIC & HYPOTENSIVE WITH SBP 70'S. IABP PLACED & DOPA GTT. PT & TRANSFERRED TO CCU. \nIABP WEANED & D/C'D, RESTARTED CARDIAC MEDS.\n\nNEURO: A&O X3. PLEASANT & COOPERATIVE.\n\nRESP: O2->2L NP. O2 SAT 95-99%. RR 12-20. BS CLEAR BUT DIMINISHED AT BASES.\n\nCARDIAC: HR 63-70 SR, NO ECTOPY. BP 95-134/41-62. FLAT UNTIL POST IABP REMOVAL. R. GROIN SITE C&D. NO EVIDENCE BLEEDING/HEMATOMA. HCT 37.5. +BPPP. C/O BACK DISCOMFORT D/T BEDREST RESTRICTION->MED X1 WITH PERCOCET 1 TAB PO WITH GOOD EFFECT.\n\nGI: APPETITE EXCELLENT. ABD. OBESE. BS+. NO STOOL, BUT PASSING FLATUS.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 20-120CC/HR.\n\nID: AFEBRILE.\n\nENDO: BS 102 REQUIRING NO COVERAGE FROM SLIDING SCALE. TO BE RESTARTED ON ORAL MEDS FOR DIABETES.\n\nAM LABS PENDING.\n\nPLAN: TRANSFER TO FLOOR TODAY.\n MANAGE HEART FAILURE MEDICALLY.\n RETURN IN 3 MO. FOR F/U WITH EP RE: VENT PACER WITH AICD.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-05-15 00:00:00.000", "description": "Report", "row_id": 1436990, "text": "CCU NPN 1900-0700\nS:\"My back is so uncomfortable, how much longer do I have to stay like this?\"\nO:Please see carevue for VS and objective data.\nCVS: Hemodynamically stable with HR 70-80's NSR, occ. PVCs, K+ 3.7, repleted with 20meq IV KCL with creat 1.4. Remains on IABP 1:1, poor augmentation. CXR done to confirm placement of IABP, in good placement per CCU team. Systolic unloading 4-11pts, diastolic unloading 2-8pts. MAPs 117-70's, IV NTG titrated as per carevue. Restarted po Carvedilol 12.5mg po. IV Heparin at 1000u/hour with PTT 45.5, therefore given 1500u bolus and rate increased to 1200u/hour, repeat PTT pnd. PLTs 245. Right groin D/I without palp. hematoma, distal pulses palp. PAP 20's/, MV 68 with CO/CI 5.3/2.29. cpk 24. Pt. denies CP, SOB.\nResp; Sats 94-98% on 2L n/c. Lungs clear with diminished bases. RR 14-21.\nGI:GU: Taking po's, one brief episode of nausea with 50cc emesis of bilious material, nausea lasted less than 1 minute, resolved spontaneously. CCU team notified. Abdomen obese with active bowel sounds, no stool, +flatus. Foley to drainage with clear, yellow urine, u/o 45-90cc/hour. U/A, C/S sent as ordered. I/O neg. 1194cc at MN.\nID: Afebrile\nNeuro: Pt. A/A/0x3, pleasant and cooperative, assisting with care as able, MAE. Requested pain med for back pain related to bedrest. Given one po Percocetx2 with good effect. Slept at intervals after usual dose po Ativan as ordered. Frequent postion changes given.\nA: stable on IABP 1:1, improved hemodynamics,\nP: Cont to monitor hemodynamics, maintain IABP, with probable wean in am. Plan to medically manage at present. Follow up with am labs. Comfort and emotional support to Pt. and family. Prn Percocet and frequent postion changes for comfort\n\n" }, { "category": "Nursing/other", "chartdate": "2193-05-14 00:00:00.000", "description": "Report", "row_id": 1436989, "text": "CCU NPN 1400-1900\nS: \"Can I sit up more?\"\nO: please see carevue and ICU admit note for complete assessment data\nBriefly this is a 66yo woman w/ known cardiac hx w/ recent decline in EF (60% by cath in , most recently 18% by P-MIBI in ) who has had multiple admissions w/ DOE. Presented to OSH w/ dyspnea, tx'd as COPD flair and CHF exacerbation, rulled out for MI. ECG w/ new LBBB and pt. experienced 2 epidosed NSVT (4/7 beats) and was transferred to for furhter eval cath/EP study.\nCath revealed R dominant circulation subtotal RCA, tortuous lesion was difficult to cross, after multiple attempts pt's SBP fell to 70s, she was diaphoretic-> IABP placed and started dopamine gtt for concern of RV infarct; intervention was aborted and pt stabilized and was able to wean off dopamine. CO/CI in lath lab 3.94/1.89. Tx'd to CCU w/ PA line and IABP in place for further management.\n\nNEURO: pt is A&Ox3, assists w/ turning in bed. C/o soreness in back from position on cath lab table-> relieved w/ 650mg tylenol. No other c/o pain.\n\nCV: 30cc IABP in place via r fem artery, waveform occasionally dampened and requiring manual flushing. 1:1 w/ fair augmentation and systolic/diastolic unloading. R femoral angio site c/d/i w/ no ooze/hematoma noted. DPs weak palp, PTs dop. Hct/lytes stable, repleted as needed. Started heparin gtt @ 1545 while IABP intact. HR NSR w/ occas PVCs, no sustained ectopy. NTG gtt titrated to maintain MAP <100, SBP 110-130. CO/CI 4.5/1.8. PAD mid-teens.\n\nRESP: RR 20s, NAD. LSCTA. SPO2 >96% on 2L NC. Cont prednisone (home med for COPD).\n\nGI: abd obese, nontender. +BS/-BM. Tolerating cardiac diet. 1.5L fluid restriction.\n\nGU: Foley draining CYU, Diuresed w/ 40mg lasix in cath lab.\n\nENDO: type 2 diabetic, written for humalog insulin SS, covered w/ 6units @ 1830.\n\nID: afebrile, no abx.\n\nSKIN: w/d/i, fungal/yeast infection under breasts and in groin, uses nystatin @ home. IABP and PA line intact R fem. PIV x 2. No breakdown noted.\n\nSOC: pt has 3 children, dtrs involved in care. Son has h/o being abusive, SW consulted and pt states that she has dealt w/ this situation and does not need any help. Family in to visit, updated by RN and MD.\n\nA: 66yo w/ new CM, EF 18%. Requiring IABP for hypotension during cath. Currently stable, tolerating IABP 1:1, awaiting EP consult for ? BiV pacer.\nP: Cont IABP onoc, ? D/c in am if pt remains stable. F/u w/ EP to eval need for pacer, ? viability study to eval ? of inferior wall defect.\n" }, { "category": "Nursing/other", "chartdate": "2193-05-16 00:00:00.000", "description": "Report", "row_id": 1436993, "text": "CCU Nursing note\nS-\"I feel pretty good today. Just tired.\"\nO-see flowsheet for additional details.\n\nEvents: Pt initally C/O to floor today but this afternoon had two episodes of hypotenstion in the high 70s c MAPs in the 40s. Each of which responded to 250cc fluid bolus. Decided to keep pt here overnight for observation unless room is needed in the unit.\n\nN-a/ox3, oob to chair and commode several times p difficulty. Steady gait. no deficits noted.\n\nCV-NSR 60s-70s c BP 96-117 c MAPs WNL beside two incidents of hypotenision as described above. +pulses. Right groin site remains stable. COntinue to follow HCT as is slowly trending down now 32.1 from 35.5 this am. EKG done this afternoon when pt was unable to decifer between her back pain vs chest pain. EKG unchanged.\n\nGI/GU/endo-foley d/c. no difficulty voiding. small bm x1. tolerating diet. Goal to run even. HISS. To start PO diabetic regimine in am.\n\nResp-Requiring O2 off and on. 1-2L at rest. LS clear/slightly diminished.\n\nID-afebrile.\n\nskin-nystatin to skin folds. psorisis on lower back. 2 PIVs.\n\nA/P-Just spoke c Dr. once again c/o to 6. Continue to monitor BP. Update pt c plan.\n" }, { "category": "Nursing/other", "chartdate": "2193-05-16 00:00:00.000", "description": "Report", "row_id": 1436994, "text": "CCU Nursing note\n1845-pt again hypotensive to the 70s c maps in the 40s. 250 cc bolus c desired response. Pt no longer c/o to floor. Plan to dose hydral to question possible adrenal insufficiency.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2161-11-05 00:00:00.000", "description": "Report", "row_id": 1567565, "text": "Nursing Progress Note 0700-1900\nS: Answers yes and no questions with help from interpreter.\n\nO: Please see carevue for complete objective data.\n\nRESP: Bronched to clear bloody secretions and verify that there was no more bleeding. RSBI-34, CPAP trial successful and ABG-7.32/45/140/-3. Extubated @ 1300. Pt sats 100 on 40% face tent, weaned to 4L nc. ABG pending. Enc C&DB, diff to clear sputum. NC 4L, RR-teens, Sats 99-100, ABG pending.\n\nCV: Post-extubation, SBP increased as high as 200. Started on labetalol gtt and titrated to SBP<150, @ 2mg/min. NSR 70-90's, no ectopy. Pulses palp, angio site CD&I. HCT-34.2.\n\nID: Mildly febrile, on tylenol ATC. On vanco/zosyn. MRSA in urine.\n\nGI/GU: NPO, taking minimal ice. BS present. Wound nurse bag, due to be changed twice a week, q mon/thurs. Stoma pink. Foley draining sedimented yellow urine. gave 10mg IV lasix c good response. -1.6L for day, +1.5L for LOS.\n\nAccess/Skin: 3 PIV's and R radial A-line. Upper lip has abrasion and is swelling. Noticed this AM, attempted to ice area post extubation. Pt does not tol ice pack on face.\n\nNeuro/Social: Sedation turned off for extubation. pt arousable, but very groggy yet. lethargic, dozing between care. Converses c family in Cantonese, does not understand much English. Lives with wife. Family into visit.\n\nA/P: 66 yo man, h/o rectal CA c bilat lung mets and isolated liver mets. S/p colon resection, severe hemoptysis requiring intubation and bronchial embolization . Evaluated by heme/onc and will follow up c CT scan when current condition improves. Cont to monitor hemodynamics and resp status. Titrate labetalol prn to maintain SBP<150. Wean O2 as tol, increase activity and diet. ?Speech and swallow eval tomorrow. Emotionally support pt and family and keep updated on plan.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-05 00:00:00.000", "description": "Report", "row_id": 1567566, "text": "Respiratory Care\nPatient had bronchoscopy at 1000 am, then got extubated around 1300 and immediately put on 40% cool aerosol via facetent, developped stridor for which he was give .5cc of Racemic epinephrine via small nebulizer, was afebrile, stayed into normal sinus rhythm, but was hypertensive almost whole day, transitioned from 40% facetent to 4L nasal cannula ABGs at 1701 7.39 42 114 26, will continue to be monitored closely.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-03 00:00:00.000", "description": "Report", "row_id": 1567556, "text": "npn 0700-0900'\n66 yr cantonese speaking gentleman with history of colonca with colostomy, being treated with chemo xeloda(9cycles )xelox(6 cycles)for mets to liver and lungs.found to have progression of disease on recent ct scan.\n\nadmitted to 7 at 0415 with hemoptysishad 2 fiuther episodes of approx 2 cups bpb and was transferred to mocu east at 0600 where he was electively intubated. at 0700 and found to have large amount of brb in bronchus.sedated with fentanyl and versed and started on propofol. and paralysed with vercuronium prior to being bronched. brb with clot in lul. s/b ip fellow who rebronched pt ,advanced ett to rt main stem to avoid and pt placed with lt side down in an attempt to avoid blood spillage into rt lung and poss tamponade to bleeding area in lung.. pt started on fentanyl and midazolam proopol off and cistatercurium drip strarted. pt remained hemodynamically stable until that pt when dropped sbp to 75 500mls lr started with fair response levophed to 1.2 mcgs/kg/min bp-78-115 .rt rad aline placed at 745 am levo weaned off after fb with bp maintained 100-120/70.\n\npt transferred by ambulance to ccu accompanied by this rn and ip fellow.with 2nd unit nurse.stable transfer bp down transiently 500 mls lr given and transiently on low dose levo until arrival in unit.where levo turned off with bp 150/50.\n\nros; neuro sedated and paralysed with fentanyl 50 mcgs/hr and midazolam 2 mgs.hr and cystastercurium .06 mg/.kg/min. did not start tof.perla 2mm.\n\nresp; 100fi02 cmv tv reduced to 300 when rt mainstem intubated. pt remained 100% sat throughout. lungs clear throughout untill ett advanced currently rtside clear absent bson lt.\n\ncvs; t 98.6 po nsr 66-75 bp 75-178/70 with 1l fb and transient levo.\n\nheme;hct pending given 20 cc of emergency release o neg prbc until hct\ncame back. repeat pending/\n\n\ngu; no u/o need foley.\n\ngi;npo need ogt. belly soft pos bs colostomy intact.\n\n\nskin ;good small abrasion over rt shin\n\nsoc; wife hcp speaks no english son at bedside translating. permission obtained by phone\n\na/p transfer to ccu and prepare for rigid bronch in or\ncheck that pt has blood in blood bank.\nplace foley and ogt.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-11-03 00:00:00.000", "description": "Report", "row_id": 1567557, "text": "respiratory care\npt trans from teh east micu, with the edo tube in his R mainstem. pt was taken to the OR. pt on the vent tol well. see respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-05 00:00:00.000", "description": "Report", "row_id": 1567563, "text": "CCU NPN 1900-0700\nO:\nID: TM 99.5po. tylenol q6hr. contin.on vanco/zosyn. vanco trough to be sent with 0600 dose.\nCV: HR 70's-90 SR. no VEA. BP 102-130/50's when sedated/quiet. period of increase agitation/wakefulness ~ 0400 - restless in bed, coughing....BP up to 160's/, HR 90 ST. required multiple bolus of fent/versed to sedate. trying to sit up, trembling. had good effect with sedation and currently BP 130/60 , HR 80.\n\nResp: suctioned q2-4hr for thick bloody/blood tinged secretions. bites on ETT (with bite block) and difficult to suction at times. LS course. copious clear oral secretions.\nvent AC 550/FIO2 decreased to .40. rate . to 16 for PCO2 37. repeat ABG 7.31/49/133-> rate inc. back to 18 at 0530. repeat ABG at 0600.\n\nGU: foley 60-80cc/hr. neg. 200cc for . pos. 2.9 LOS.\nGI: OGT in place. pos. placement by auscultation. green bile aspirates for total 150cc. guiac neg. no stool from ostomy\nneuro: as above, requiring boluses of fent/versed. remains on fent. 50mcq/hr and versed 4mg/hr. moving all extrem. bilat. hands restrained per policy.\nskin: intact. upper lip swollen from bite block. right fem. site D/I. pulses 3+/1+\naccess: PIV x3, right rad. aline.\n\nA: 44yomale with colon ca with lung mets. s/p bronchial artery embolization . contin. to bloody secretions- plan to attempt vent wean today. unable to obtain RSBI d/t sedation requirment.\nP: follow plan for vent wean- PS trial. follow hCT , lytes.\ntitrate sedation for comfort.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-05 00:00:00.000", "description": "Report", "row_id": 1567564, "text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on full ventilatory support. WE made vent changes by routibe ABG, WE are sxtn for bloody/ Blood tinged secretions from ETT. He bites on ETT even with oral airway. Plan: Continue present ICU monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-03 00:00:00.000", "description": "Report", "row_id": 1567558, "text": "66 YR OLD C MET CA OF RECTUM(,COLOSTOMY) AND LUNGS UNDER GOING CHEMOTHERAPY ADMITTED C 3 DAY HX HEMOPTYSIS .INTUBATED 4AM TO R LUNG AS BLEEDING IN L.TRANSFERRED TO TO CCU PARALYZED,SEDATED AND HYPOTENSIVE. THEN DIRECTLY TO OR FOR RIDGID BRONCH,TUMOR ABLATION AND DESTRUCTION.RETURNED FROM OR HYPERTENSIVE,PARALYTICS DC,SPIKING TEMP TO 103.9.LABETOLOL TITRATED FOR BP.BLOOD,URINE CX SENT .STARTED ON ANTIBX.TYLENOL, DEMEROL FOR RIGORS.SEEN BY ANESTHESIA TO RO POST MALIGNANT HYPERTHERMIA.SEEN BY INTERVENTIONAL ANGIO,PLAN FOR EMBOLIZATION TOMORROW IF PT REMAINS STABLE .CT SCAN ON HOLD .ON CMV ,BS COARSE .SAT 100,LG CLOT X1.LIDOCAINE ORDERED DOWN ETT TO SUPRESS\nCOUGHING .ABG 7.41/42/109/28.NSR 80S TO 90S .HCT STABLE 34.LABETOLOL OFF ,BP IN THE 90S.OG IN PLACE,COFFEE GNDS .POS BS .CYU IN GOOD AMTS VIA FOLEY .SEDATED ON VERSED AND FENTANYL.FLEXES TO NOXIOUS STIMULATION.FAMILY AT BEDSIDE .MONITOR FOR BLEEDING.SUPPRESS COUGH .KEEP SEDATED\n" }, { "category": "Nursing/other", "chartdate": "2161-11-04 00:00:00.000", "description": "Report", "row_id": 1567559, "text": "Resp Care\nPt remained intubated and ventilated on a/c with no remarkable changes overnight. ABGS with good oxygenation, normal limits. No spontaneous breaths noted.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-04 00:00:00.000", "description": "Report", "row_id": 1567560, "text": "ccu nsg progress note-micu border.\n66yo male w significant pmh--rectal/colon ca requiring resection. subsequently dx w metastatic pulmonary nodules -aggressively rxed, but continued progression of disease & further rxed dced . developed hemoptysis. admitted. electively intubated/bronched. rigid bronch w tumor ablation & scheduled for bronchial artery ablation on . code status-presently full code.\n\no:neuro=minimally responsive. sedated w fent/versed gtts. soft restraints to upper extrem for safety.\n pulm=intubated/vented w present settings-ac/55x20/50%/+5 w sats-100% & am abg-pending. breath sounds=course throughout. sx x1-dark bl secretions.\n cv=hemody stable. borderline bp-bolused w 500ml ns x1.\n gi=npo.\n heme=am hct-31.2.\n gu=decreased uo.\n id=low grade t. abx-vanco & pippercillin. precautions-msra urine.\n labs=am sent.\n\na:wo further bl over night. slowly trending down hct.\n\np:contin present management. ?bronchial artery ablation verse further observation. support family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-04 00:00:00.000", "description": "Report", "row_id": 1567561, "text": "Respiratory Care\nPt remain intubated and on vent support. Vent changes were from A/C to PSV w/CPAP 10/5. Pt has good volumes and rate. Lung sounds were course throughout and slightly dim in the bases. Tube was advanced today to 28 cm @ the lip after a bronch. RN and I heard Lung sounds, CXR was ordered. Pt was bronched to check for active bleeding. No active bleeding observed during bronch. Pt then transported to IR for a bronchial arterial embolization. No events during trip. No ABG's were drawn during shift. Care plan is to continue to wean pt and obtain a RSBI and SBT tomorrow. ? of extubation tomrrow. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-04 00:00:00.000", "description": "Report", "row_id": 1567562, "text": "Nursing Progress Note 0700-1900\nS: Mechanically ventilated.\n\nO: Please see carevue for complete objective data.\n\nRESP: in AM, vented on AC 20*550, 50%, 5PEEP. Bronch @ bedside revealed no active bleeding. ETT advanced to 28 @ the lip attending MD. placement. Pt to IR for Bronchial Artery Embolization to resolve hemoptysis. Procedure successful.\n\nStarted weaning the vent upon arrival back to unit. Placed on CPAP 50%, 5PEEP/10PS. Tolerating well. ABG pending. Lungs coarse, sxn'd rarely for minimal bloody secretions. Unable to obtain sputum cx. Strong cough and gag. Sats in 100's, Spon RR ~ 12. Muoth care done.\n\nCV: NSR, 70-80's, no ectopy. bronchial artery repaired via Right femoral artery, sheath pulled in IR and hemostasis occurred @ 1430. Site CD&I, no hematoma, transparent dressing. Pulses palp. SBP 79-120's, OFF labetalol gtt, became hypotensive r/t sedation. Gave 500cc IVFB c some improvement. pneumo boots on. HCT-30.2(31.2)\n\nGI/GU: NGT placement confirmed, attached to sxn this AM. small amount bilious emesis. Clamped for med administration. BS present, colostomy bag intact, not changed. Foley draining clr yel/amb urine. Rec'd 185cc of dye in IR and 500cc IVFB for BP. Lytes repleted, +3.5L for LOS.\n\nID: mildly febrile, Tmax 100.7, on tylenol ATC. On Zosyn Q6h and Vanco Q12h.\n\nAccess/Skin: 3 PIV's, R radial art line. No skin issues, stoma site covered c bag.\n\nNeuro/Social: Sedated on Versed 4mg/hr & Fentanyl 50mcg/hr. Arouses to voice, and obey commands occas. Knee immobilizer on R. Wrist retraints for line integrity. Dtr say that he can understand \"some\" english, but cantonese is primary language. 2 Dtrs and wife into visit today. Updated by RN and MD's.\n\nA: 66 yo cantonese man c rectal CA s/p resection and colostomy. CA metastasized to lungs, massive hemoptyic episode requiring intubation. -in OR-rigid bronch c tumor ablation/destruction. ?poss malignant hyperthermia r/t anesthesia, febrile to 104, hypertensive, rigoring, labetalol gtt started.\n\nproblems resolved , OFF labetalol. Repaired bronchial artery in IR, attempting to wean off vent.\n\nP: Cont to monitor hemodynamics and resp status. Follow ABG's and cont to wean sedation and vent as tol. RSBI in AM for ?poss extubation. Repeat HCT @ 2100, Vanco trough due @ 0600. Emotionally support pt and family and keep updated on plan.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-06 00:00:00.000", "description": "Report", "row_id": 1567567, "text": "Nursing Note 7p-7a\n\nS/O: See careview for complete data.\n Received pt alert/oriented & cooperative. Communicating thru his son, he was able to follow commands & make needs known. PEARL/MAE in bed.\nCV- Tele SR no vea, HR 70s-80s. ABPs 105-150/56-70s. Labetalol gtt currently infusing @ 1.5 mg/min to maintain SBPs < 150. HCT stable @ 30.7, Plts 95, lytes wnls. R fem site cd+i.\nResp- LS coarse throughout, conts on 4L nc w/sats 94-99%. Frequent (strong) coughing spasms that occ produce thick tan/blood tinged sputum. No hemoptysis.\nGI/GU- NPO except ice chips. Colostomy intact, stoma pink/protruding no stool. Vomited bile x2, OB-. Given anzumet x1 w/ no relief. NGT dropped and placed on conts lws, placement confirmed by . Conts on ppi. Voiding qs yellow urine, Cre 1.1, no lasix. 24hr balance -310, LOS +1050.\nID- Precautions for MRSA in urine. Tmax 100.4 po, conts on Vanco/zosyn ?asp PNA. All cx's still pending.\nSkin- Upper lip abrasion/swelling from bite block resolving.\nA/P: 66yo male dx w/metastatic rectal cancer w/mets to lungs p/w massive hemoptysis. Elective intubation-> R lobe. S/p ridged bronch w/ tumor ablation in LUL on . Temp spiked to 104 w/ rigors & hypertensive. ? Malignant hyperthermia d/t anesthesia. Placed on labetalol gtt. On underwent success bronch artery embolization, R groin site cd+i. Cont plan of care, monitor BPs & resp status. Wean labetalol as tol. Support pt/family, poss meeting to discuss plan of care d/t poor dx.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-06 00:00:00.000", "description": "Report", "row_id": 1567568, "text": "66 yr c met rectal ca to lungs sp tumor ablation and bronchial artery embolization ,ext .NSR NO ECT ,LABETOLOL DC ,NOW ON IV LOPRESSER FOR BP 120 TO 150 SYS.NO PAIN.NO SOB .BS COARSE,DECREASED IN BASES .SAT 98 0N 4L NP .C/R TAN BLOOD TINGED .NG TO SX FOR 500 CC GREEN SINCE 10 PM .VOMITED WHEN NG CLAMPED.KUB DONE .NO ILEUS .LACTULOSE ,REGLAN GIVEN .SM AMT BR SOFT STOOL IN COLOSTOMY .SAYS HE IS HUNGRY.CYU VIA FOLEY .OOB TO CHAIR X 2,UNSTEADY ON FEET.ALERT,ORIENTED ,COOPERATIVE.FAMILY VISITING ALL DAY.FOR TRANSFER.\n" }, { "category": "Nursing/other", "chartdate": "2161-11-07 00:00:00.000", "description": "Report", "row_id": 1567569, "text": "ccu nsg progress note-micu border.\no:stable throughout night. ngt to sx (intermittent)-bilious drainage. despite addition-lactulose/metoclopramide-wo stool. wo further nausea/vomiting. tolerating ice chips. productive cough-thick sl bl tinged secretions. abx-vanco/pipercillin as ordered. am labs sent.\n\na:awaiting o-med bed.\n\nP:contin present management. transfer to o-med when bed available. support as indicated.\n" }, { "category": "Radiology", "chartdate": "2161-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933867, "text": " 11:23 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: position of ett\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with renal cell carcinoma with large volume hemoptysis s/p\n intubation\n REASON FOR THIS EXAMINATION:\n position of ett\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Large volume hemoptysis in a patient with renal cell\n carcinoma, status post intubation.\n\n Portable AP chest radiograph compared to a previous film done the same day\n earlier at 05:54 a.m.\n\n The patient has been intubated in the meantime interval with the ET tube tip 7\n cm above the carina. The NG tube tip is within the stomach.\n\n The heterogeneous peribronchial opacification in the left mid lower lung zone\n has markedly worsened consistent with large intraparenchymal hemorrhage at the\n area of known lung metastasis. The right lower lung opacification has been\n also increased. The left lower lobe collapse is new most likely due to\n endobronchial aspiration of hemoptysis. There is no sizeable right pleural\n effusion, but small left pleural effusion cannot be excluded.\n\n IMPRESSION:\n\n New large consolidation in the left lung consistent with hemoptysis with\n subsequent most likely blood aspiration and left lower lobe collapse.\n Worsening of right lower lung opacity could also be related to aspiration.\n\n These findings were communicated with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2161-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934276, "text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change, ?aspiration event.\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with renal cell carcinoma with large volume hemoptysis.\n Recent episodes of vomiting with new decreased breath sounds in the right base\n and copious tan sputum production.\n REASON FOR THIS EXAMINATION:\n Interval change, ?aspiration event.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:33 A.M., :\n\n HISTORY: End-stage renal cell carcinoma and hemoptysis.\n\n IMPRESSION: AP chest compared to at 9:12 a.m.\n\n Consolidation at the right base has improved and represent clearing of some\n aspiration. Left lower lobe consolidation is stable. Vascular congestion.\n Surrounding the partially cavitated metastasis in the left mid lung is\n unchanged. There is no appreciable pleural effusion. Heart size normal. No\n pneumothorax. Nasogastric tube passes into the stomach and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-11-10 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 934847, "text": " 1:20 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: please evaluate for SBO\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with metastatic rectal cancer, recently intubated with partial\n SBO on abd. CT yesterday\n REASON FOR THIS EXAMINATION:\n please evaluate for SBO\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdominal supine and erect films.\n\n INDICATION: 66-year-old gentleman with a history of metastatic rectal\n cancer and partial small-bowel obstruction on recent CT scan.\n\n COMPARISON: Comparison is made to the prior CT study dated .\n\n ABDOMEN, SUPINE AND ERECT RADIOGRAPH: There are multiple dilated loops of\n small bowel with air-fluid levels, consistent with small-bowel obstruction.\n On today's study, there is contrast material seen within the colon that was\n not present on the previous CT study suggesting partial obstruction as\n contrast material from the previous day's exam has progressed as seen on the\n film. There is no free air under the diaphragms. There are several surgical\n clips noted within the pelvis. There are no significant soft tissue or\n osseous abnormalities noted.\n\n IMPRESSION: Partial small-bowel obstruction. Progression of oral contrast\n into colon compared to previous study.\n\n" }, { "category": "Radiology", "chartdate": "2161-11-09 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 934687, "text": " 1:16 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: please evaluate for interval staging\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with colon CA with known lung mets.\n REASON FOR THIS EXAMINATION:\n please evaluate for interval staging\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male with colon CA and known lung metastases. Evaluate\n for interval staging.\n\n Comparison is made to prior CT torso dated .\n\n TECHNIQUE: Non-contrast and contrast enhanced axial CT imaging of the chest,\n abdomen and pelvis was reviewed.\n\n CT CHEST WITH CONTRAST: There are numerous bilateral pulmonary nodules, the\n largest measuring 2.5 x 2 cm, slightly diminished from prior examination where\n it measured 2.2 x 3 cm within the left upper lobe. Many of the nodules appear\n slightly increased in size and there is new appearance of large nodules in the\n right lower lobe and abutting the left major fissure. There are new bilateral\n pleural effusions, left greater than right with some consolidation or\n atelectasis of the left lower lobe abutting the pleural effusion. There is\n dependent atelectasis within the right lower lobe. There is a grossly\n unchanged appearance to subaortic lymphadenopathy measuring 18.7 x 8.6 mm on\n today's examination. No pathologic axillary nodes are identified and the\n heart and great vessels appear normal.\n\n CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST: The liver enhances homogenously\n and again identified is a small 6 mm hypodensity in the left lobe (segment\n III), unchanged from prior examination and a larger well defined hypodensity\n within the inferior tip of the right lobe measuring approximately 11 x 15 mm\n on current examination, previously measuring 21 x 14 mm which are concerning\n for metastases. The gallbladder, pancreas, spleen, adrenal glands, and\n kidneys are unremarkable. There are multiple dilated loops of small bowel\n with a questionable transition zone within the left lower quadrant followed by\n distal decompressed loops, concerning for small bowel obstruction. No oral\n contrast is identified distal to this point. There is a mild- moderate amuont\n of ascites surrounding the liver. There is no free air or pathologic\n mesenteric or retroperitoneal lymphadenopathy identified.\n\n CT PELVIS WITH IV CONTRAST: The patient is status post diverting colostomy. A\n previously mentioned increased soft tissue density in the presacral area is\n again identified unchanged from prior examination, likely representing\n postsurgical changes versus stable recurrent tumor. Multiple surgical clips\n are again identified. The distal ureters and bladder appear normal.\n\n (Over)\n\n 1:16 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: please evaluate for interval staging\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: No suspicious osteolytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1. New and increased size of bilateral pulmonary nodules with mild decrease\n in size of most dominant nodule. Bilateral pleural effusions, left greater\n than right.\n\n 2. Unchanged left lobe lesion with better definition of right inferior lobe\n hypoattenuating lesion, concerning for metastasis.\n\n 3. Dilated loops of small bowel with questionable transition zone within left\n lower quadrant. Likely represents partial small bowel obstruction,\n coorelation with clinical symptoms suggested\n\n The above findings were communicated to the ordering physician, . on\n the date of examination at approximately 6:00 p.m.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2161-11-04 00:00:00.000", "description": "EMBO NON NEURO", "row_id": 933956, "text": " 8:05 AM\n BRONCHIAL Clip # \n Reason: pt needs embolization of the suspected bleeding source\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: OPTIRAY Amt: 185CC\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO 2ND ORDER /BRACHIOCEPHALIC *\n * -51 MULTI-PROCEDURE SAME DAY TRANCATHETER EMBOLIZATION *\n * F/U STATUS INFUSION/EMBO THORACIC ANGIOGRAM *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1887 CATHETER GUIDING INF/PERF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with hx rectal CA with hemoptysis s/p cauderization to L\n mainstem bronchus, now with recurrent hemoptysis.\n REASON FOR THIS EXAMINATION:\n pt needs embolization of the suspected bleeding source\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Bronchial artery embolization, via right transfemoral approach.\n\n OPERATORS: , M.D. (staff, supervising and attending throughout\n the course of the procedure.)\n , M.D.(IR fellow).\n , M.D. (Radiology resident).\n\n CLINICAL DIAGNOSIS: Colorectal carcinoma with metastatic disease to lung.\n Hemoptysis. Bronchial artery bleeding.\n\n DESCRIPTION OF PROCEDURE: After appropriate informed consent and timeout was\n performed, the patient was positioned in supine fashion on a special\n procedures table. The patient arrived to the department intubated and on a\n ventilator. The right groin was prepped and draped in usual sterile fashion.\n The skin and subcutaneous tissues were infiltrated with a total of 10 cc of 1%\n Xylocaine for local anesthesia. Uneventful one-wall, retrograde, arterial\n puncture was achieved at the right common femoral artery. A 0.035 inch\n Bentson guidewire was advanced to the abdominal aorta level. Subsequently, the\n needle was removed and exchanged for a 5 French vascular sheath which was\n connected to a sidearm, heparinized saline flush. Under fluoroscopy, a 5\n French pigtail catheter was advanced to the aortic arch level. Two flush\n injections were performed using digital subtraction technique. The aortic arch\n injection depicts a normal pattern of blood flow. Subsequent to satisfactory\n imaging, the pigtail was removed over a guidewire and exchanged for a 5 French\n catheter, which was used to selectively engage a common trunk giving\n rise to right and left bronchial arteries.. Using roadmapping and puff test\n injections of contrast, the left-sided branch was selectively catheterized\n using a 3 French Renegade microcatheter - 0.018- inch golden glide guidewire.\n A diagnostic arteriogram was performed where supply to the area of bleeding\n was demonstrated. There was a normal pattern of blood flow observed.\n Specifically, extravasation of contrast was not demonstrated. However, empiric\n (Over)\n\n 8:05 AM\n BRONCHIAL Clip # \n Reason: pt needs embolization of the suspected bleeding source\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: OPTIRAY Amt: 185CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n transcatheter embolization of the left bronchial artery was performed using\n one syringe of 300-500 micron Embospheres. Subsequently, a post- embolization\n angiogram demonstrates near complete stasis in the bronchial artery branch.\n This was followed with deployment of Gelfoam slurry particles, (5 cc total),\n unti stasis was achieved.\n\n ESTIMATED BLOOD LOSS: Minimum.\n\n COMPLICATIONS: None immediately.\n\n IMPRESSION: Successful transcatheter embolization of successful empiric\n embolization of left-sided bronchial artery. Post-procedural orders were\n written.\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2161-11-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934041, "text": " 4:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval ET tube placement\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with renal cell carcinoma with large volume hemoptysis\n intubated, advanced ET tube\n REASON FOR THIS EXAMINATION:\n eval ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal cell carcinoma, hemoptysis.\n\n COMPARISON: .\n\n FINDINGS: Endotracheal tube has been advanced, and now terminates at\n approximately 3 cm above the carina. Nasogastric tube courses below the\n diaphragm and out of view. There is essentially unchanged appearance of left\n lower lobe consolidation, left perihilar opacification surrounding the\n metastasis. There is unchanged left pleural effusion. Cardiomediastinal\n silhouette is top normal, unchanged. Right lung is grossly clear, except\n small metastatic nodules.\n\n IMPRESSION: Interval advancement of endotracheal tube, which now terminates 3\n cm above the carina. Otherwise, unchanged appearance of the chest from\n previous examination , 7:00 a.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-11-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933949, "text": " 7:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with renal cell carcinoma with large volume hemoptysis s/p\n cauderization\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:29 A.M., \n\n HISTORY: Renal cell carcinoma. Hemoptysis.\n\n IMPRESSION: AP chest compared to :\n\n Left lower lobe consolidation persists, and there is more opacification\n surrounding the left juxtahilar metastasis presumably bleeding source,\n suggesting an interval increase in aspirated pulmonary hemorrhage. Right lung\n is grossly clear aside from smaller metastases. Small left pleural effusion\n is larger. Cardiomediastinal silhouette is midline and heart size is top\n normal. ET tube and nasogastric tube are in standard placements. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-11-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 933792, "text": " 1:22 AM\n CHEST (PA & LAT) Clip # \n Reason: Rule out infective cause, asses for acute cardiopulmonary pr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with haemoptysis, h/o of metastatic disease to lungs\n REASON FOR THIS EXAMINATION:\n Rule out infective cause, asses for acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with hemoptysis and history of metastatic disease\n to the lungs, for evaluation for infective or acute cardiopulmonary\n abnormality.\n\n COMPARISON: CT of the torso from .\n\n PA AND LATERAL CHEST RADIOGRAPHS: Again seen are multiple nodular opacities\n corresponding to the patient's known pulmonary metastases, the largest of\n which is seen in the left mid lung zone. No consolidative opacities are\n identified. No pleural effusions or pneumothorax is seen. The pulmonary\n vasculature is within normal limits. The heart is at the upper limits of\n normal. The mediastinal contours are within normal limits. The soft tissue\n and osseous structures are unremarkable.\n\n IMPRESSION: Nodular opacities are seen, consistent with the patient's known\n history of pulmonary metastases. No acute cardiopulmonary abnormalities\n identified.\n\n" }, { "category": "Radiology", "chartdate": "2161-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934243, "text": " 9:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval NGT placement and for signs of aspiration\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with renal cell carcinoma with large volume hemoptysis.\n Recent episodes of vomiting\n REASON FOR THIS EXAMINATION:\n eval NGT placement and for signs of aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of renal cell carcinoma with hemoptysis. Recent\n vomiting, evaluate nasogastric tube placement and aspiration.\n\n COMPARISON: .\n\n FINDINGS: The patient is rotated to the left.\n\n Patient has been extubated in the interval. Nasogastric tube is in place,\n courses below the diaphragm and out of view. There is now an apparent\n cavitation in one of the lesions in the left perihilar region. Appearance of\n other nodules is unchanged. There is a right lower lobe density, not\n significantly changed from the other study, and improving retrocardiac\n density, that could represent consolidation versus atelectasis. There are no\n large pleural effusions. Pulmonary vascularity is normal.\n\n IMPRESSION: Similar appearance of right lower lobe consolidation, improving\n left lower lobe density, representing consolidation versus atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-11-06 00:00:00.000", "description": "P ABDOMEN (SUPINE & ERECT) PORT", "row_id": 934324, "text": " 12:32 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: eval for obstruction\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with RCC met to lungs with increased emesis s/p extubation\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with RCC, met to lungs with increased emesis\n status post extubation. Evaluate for obstruction.\n\n COMPARISON: CT torso .\n\n FINDINGS: Two supine and upright plain radiographs of the abdomen are\n obtained. Of note, the pelvis is not seen on these images. The bowel gas\n pattern is unremarkable and there is no evidence of obstruction. An NG tube\n appears to be positioned in the stomach with the tip pointing towards the\n antrum. Note is made of a left lower quadrant colostomy. Surgical clips are\n identified within the upper pelvis. Evaluation of the lower lung fields\n reveals a small left-sided pleural effusion and suggestion of left-sided\n atelectasis. Osseous structures are unremarkable.\n\n IMPRESSION: No evidence of obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-11-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 934562, "text": " 3:01 PM\n CHEST (PA & LAT) Clip # \n Reason: please eval for infiltrate, effusion\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with haemoptysis, h/o of metastatic disease to lungs\n\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hemoptysis.\n\n Three radiographs of the chest demonstrate increased bibasilar airspace\n opacities. There is probably a small left-sided effusion. Cardiomediastinal\n contours are unchanged compared with . The nasogastric tube has been\n removed. There is no pneumothorax.\n\n IMPRESSION:\n\n Small left-sided pleural effusion and bibasilar airspace opacities.\n Diagnostic considerations include aspiration. Pneumonia is not excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933805, "text": " 5:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusions, hemorrhage, aspiration\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with renal cell carcinoma with large volume hemoptysis.\n REASON FOR THIS EXAMINATION:\n effusions, hemorrhage, aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Renal cell carcinoma. Large scale hemoptysis.\n\n IMPRESSION: AP chest compared to and :\n\n Since . The heterogeneous peribronchial opacification in the left\n mid and right lower lung zones has improved consistent with clearance of\n pulmonary hemorrhage, presumably arising from one of multiple pulmonary\n metastases, the largest in the left mid lung, approximately 27 mm across,\n compared to 22 mm on .\n\n No pleural effusion. Cardiomediastinal silhouette is unremarkable. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934101, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with renal cell carcinoma with large volume hemoptysis\n intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in a patient after large volume\n hemoptysis.\n\n Portable AP chest radiograph compared to made at 16:24 p.m.\n The ET tube tip is 1.8 cm above the carina. The NG tube is in the stomach.\n The heart size is enlarged, but stable. There is no change in the appearance\n of the mediastinum. The left lower lobe atelectasis and the juxtahilar\n opacity surrounding the known pulmonary metastasis are grossly unchanged as\n well as the right lower lobe consolidation.\n\n IMPRESSION: No significant change compared to the previous film.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-11-11 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 934940, "text": " 8:55 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: please evaluate for interval changes in SBO\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with metastatic rectal cancer and partial sbo\n REASON FOR THIS EXAMINATION:\n please evaluate for interval changes in SBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Radiographic suspicion for SBO. Followup.\n\n ABDOMEN, TWO VIEWS: Comparison with examination from . Again\n seen are multiple gas and fluid filled dilated loops of small bowel in a\n pattern similar to the previous examination. Contrast has progressed slightly\n through the colon. Again seen are multiple surgical clips overlying the\n sacrum and the left hemipelvis. No free air seen under the diaphragms. No NG\n tube is present. Bony structures are unchanged.\n\n IMPRESSION: Similar appearance of multiple air and fluid filled loops of\n bowel, with interval progression of contrast.\n\n" } ]

[ { "category": "ECG", "chartdate": "2198-12-31 00:00:00.000", "description": "Report", "row_id": 264824, "text": "Artifact is present. Atrial fibrillation with a rapid ventricular response.\nNon-specific ST-T wave changes. Compared to the previous tracing atrial\nflutter has converted to atrial fibrillation.\n\n" }, { "category": "ECG", "chartdate": "2198-12-31 00:00:00.000", "description": "Report", "row_id": 264825, "text": "Atrial flutter. Since the previous tracing of same date the ventricular rate is\nslower.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2198-12-31 00:00:00.000", "description": "Report", "row_id": 264826, "text": "Atrial flutter with a rapid ventricular response. Borderline low limb lead\nQRS voltage is non-specific. Since the previous tracing of atrial\nflutter has replaced sinus rhythm.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2126-08-15 00:00:00.000", "description": "Report", "row_id": 69470, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Preoperative assessment.\nHeight: (in) 72\nWeight (lb): 207\nBSA (m2): 2.16 m2\nBP (mm Hg): 135/74\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 17:01\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Normal regional LV\nsystolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Moderately dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. There is mild symmetric left ventricular hypertrophy with normal cavity\nsize. Regional left ventricular wall motion is normal.\n2. The aortic root is moderately dilated. The ascending aorta is moderately\ndilated.\n3. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n5. There is mild pulmonary artery systolic hypertension.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-08-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 879391, "text": " 7:17 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval ptx\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p cath, 3 VD, needs CABG\n\n REASON FOR THIS EXAMINATION:\n eval ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male status post catheterization, 3 vessel disease,\n needs CABG. Evaluate for pneumothorax.\n\n There has been interval removal of a right Swan-Ganz catheter. Midline and\n pleural drains remain unchanged in standard positions. Small right apical\n pneumothorax is unchanged in size from ___30/05. A very small, approximately\n 5%, apical pneumothorax is also noted at the left side. Left retrocardiac\n heterogeneous opacification could be atelectasis or developing pneumonia and\n is unchanged. Lungs are otherwise clear. There is stable cardiomegaly. The\n mediastinal and hilar contours are stable. The visualized osseous structures\n are grossly normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-08-16 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 878784, "text": " 8:16 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre-op eval - ? carotid stenosis\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man, with HTN, s/p cath, needs CABG\n REASON FOR THIS EXAMINATION:\n pre-op eval - ? carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID SERIES COMPLETE.\n\n REASON: Preop for CABG.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\n plaque was identified.\n\n The peak systolic velocities are 73, 73, 79 in the ICA, CCA, ECA respectively.\n The ICA to CCA ratio is 1. This is consistent with less than 40% stenosis.\n\n On the left, peak systolic velocities are 120, 100, 88 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 1.2. This is consistent with less than\n 40% stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-08-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 879467, "text": " 4:01 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p ct dc, eval ptx's\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p cath, 3 VD, s/p CABG\n REASON FOR THIS EXAMINATION:\n s/p ct dc, eval ptx's\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male status post CABG with recent removal of chest\n tube. Evaluate for pneumothorax.\n\n COMPARISONS: Comparison is made to AP chest radiograph from \n at 11:11.\n\n TECHNIQUE/FINDINGS: PA and lateral chest radiographs were reviewed. There\n has been interval removal of a left-sided chest tube. No pneumothorax is\n identified. The patient is status post CABG with median sternotomy. Small\n bilateral apical pneumothoraces are unchanged. Interval improvement in left\n retrocardiac consolidation reflects likely resolving atelectasis. There is\n mild congestion of the pulmonary vasculature but no overt pulmonary edema.\n\n IMPRESSION:\n 1. Unchanged bilateral small apical pneumothoraces.\n 2. Improving left lower lobe atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2126-08-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 879218, "text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ptx\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p cabg x4\n\n REASON FOR THIS EXAMINATION:\n assess ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AT 7:28 A.M. ON .\n\n HISTORY: Status post CABG. Assess pneumothorax.\n\n IMPRESSION: AP chest compared to at 3:31 p.m.\n\n Small right apical pneumothorax is unchanged in size, apex at the fourth\n posterior interspace. Lung volumes are lower following extubation\n exaggerating borderline interstitial edema. Small bilateral pleural effusions\n are unchanged. Tip of Swan-Ganz catheter projects over the pulmonic valve.\n Midline left pleural drain is in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-08-15 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 878707, "text": " 2:48 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: +ETT\\CATH\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p cath, 3 VD, needs CABG\n REASON FOR THIS EXAMINATION:\n pre-op eval - ?PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST X-RAY OF \n\n CLINICAL INDICATION: Coronary artery disease. Preoperative evaluation.\n\n Please note that the patient was unable to undergo a lateral chest radiograph\n or to sit upright for the PA view due to recent catheterization. Therefore, a\n single AP view of the chest was obtained.\n\n Allowing for AP technique, the heart is upper limits of normal in size. The\n aorta is tortuous and the pulmonary vascularity is normal. The imaged\n portions of the lungs are grossly clear, but the extreme right costophrenic\n angle has been excluded from the study and cannot be fully assessed. This\n limits assessment of a small portion of the right lung base and also limits\n assessment for small right pleural effusion. Degenerative changes are seen\n within the spine.\n\n IMPRESSION: No evidence of acute cardiopulmonary process on this limited\n chest radiograph. Standard PA and lateral views are recommended for more\n complete assessment of the chest when the patient's condition permits.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-08-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 879424, "text": " 10:51 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct p[ull r/o ptx\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p cath, 3 VD, needs CABG\n\n REASON FOR THIS EXAMINATION:\n s/p ct p[ull r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:11 A.M. ON \n\n HISTORY: CABG.\n\n IMPRESSION: AP chest compared to at 8:07 a.m.\n\n Small right apical pneumothorax is unchanged. Mediastinal caliber is stable\n following removal of midline drains. Small left pleural effusion is\n unchanged. Left basal chest tube is unchanged in position and sharply bent at\n tip. Tiny left apical pneumothorax is more readily visible but not\n appreciably larger than it was earlier. Left lower lobe atelectasis is\n stable. Right lung is essentially clear.\n\n A clearly visible sternal wound lucency is of no clinical significance in the\n early postoperative period. Sternal wires are intact.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-08-16 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 878789, "text": " 8:44 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: +ETT\\CATH\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p cath, 3 VD, needs CABG\n\n REASON FOR THIS EXAMINATION:\n unable to do lateral yesterday only PA was done - please do PA if necessary/LA\n today to complete study ?acute cardiopulmonry process?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Preoperative chest radiographs prior to coronary bypass surgery.\n\n PA AND LATERAL CHEST: Cardiac size is at the upper limits of normal. There\n is no overt CHF, pleural effusion, or focal consolidation. Faint minimal\n interstitial opacities are present, which may be related to chronic mild\n edema. Osseous structures are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-08-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 879140, "text": " 1:11 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p cabg x4\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW, PORTABLE\n\n INDICATION: 75-year-old man, status post CABG.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared to the previous study of .\n\n The patient is status post CABG and median sternotomy. The tip of the\n endotracheal tube is identified at thoracic inlet. The right jugular\n Swan-Ganz catheter terminates in the main PA. A nasogastric tube courses\n towards the stomach. The left chest tube and mediastinal drain remain in\n place.\n\n There is mild congestive heart failure with cardiomegaly and left lower lobe\n atelectasis, which is associated with small left pleural effusion. No\n pneumothorax is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-08-19 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 879168, "text": " 3:37 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: PLEASE REPEAT\n Admitting Diagnosis: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p cabg x4\n\n REASON FOR THIS EXAMINATION:\n PLEASE REPEAT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW PORTABLE.\n\n INDICATION: 75-year-old man, status post CABG.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study at 2:46 p.m.\n\n There is new right apical pneumothorax (10%).\n\n The patient is status post CABG and median sternotomy. The tip of the\n endotracheal tube is identified at the thoracic inlet. The left chest tube\n and mediastinal drain remain in place. A nasogastric tube terminates in the\n stomach. There is continued left lower lobe atelectasis. The previously\n identified mild congestive heart failure has been slightly improving. There\n is continued mild cardiomegaly.\n\n IMPRESSION: Small right apical pneumothorax (10%). The information was\n communicated with Dr. .\n\n\n" }, { "category": "ECG", "chartdate": "2126-08-19 00:00:00.000", "description": "Report", "row_id": 163162, "text": "Sinus rhythm\nBorderline first degree A-V delay\nProbable left atrial abnormality\nEarly precordial QRS transition - is nonspecific\nModest diffuse nonspecific ST-T wave abnormalities\nSince previous tracing of , further T wave changes present\n\n" }, { "category": "ECG", "chartdate": "2126-08-14 00:00:00.000", "description": "Report", "row_id": 163163, "text": "Sinus rhythm with ventricular premature depolarizations. Non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of no\nmajor change.\n\n" }, { "category": "Nursing/other", "chartdate": "2126-08-19 00:00:00.000", "description": "Report", "row_id": 1302944, "text": "PT S/P CABG X4. OR EVENTFUL FOR DEFIB X4 OFF PUMP FOR VT STARTED ON LIDOCAINE GTT. ALSO PLT 60'S RECEIVED 15PK INTRA OP. ARRIVED IN CSRU ON NEO/PROP/LIDO WITH CORE TEMP 34.1. BAIR HUGGER PLACED. ASSESSMENT IS AS FOLLOWS\nNEURO: AFTER WARM, PROP WEANED OFF AND REVERSALS GIVEN. NOW AWAKE AND FOLLOWING COMMANDS BUT SLEEPY. MSO4 X2 FOR C/O PAIN PER PT. PUPILS UNEQUAL. RT>LT PT HAS HAD CATARACT AND LENS IMPLANT IN THAT EYE. PT MAE. FOLLOWS COMMANDS. M. COURNTEY AWARE.\nCV: HR 60-80'S NSR SLIGHTLY PROPLONGED PR AT 0.24. RARE PVC NOTED. CONTINUES ON LIDO 2MG/MIN. NEO WEANED TO OFF. BP 120'S/50'S. DOPPLERABLE PULSES. CT WITHOUT SIGNIFICANT DRNG. NO LEAK. INR NOW 1.4. 2 FFP GIVEN IN CSRU FOR POST OP INR 1.8 DESPITE LACK OF BLEEDING. 2A 2V WIRES TO BOX BUT OFF. SEE FLOWSHEET FOR THRESHOLDS. CI>2.3. CVP 9-12, PAD 16-20. LR 500CC.\nRESP: LUNGS CLEAR BUT DIM BASES. CURRENTLY ON CPAP PS 10 AND PEEP 5 FIO2 40% WITH TV 300'S AND RR 20'S. ABG PENDING NEED TO RETURN TO IMV UNTIL MORE AWAKE.\nGI: OGT TO LCWS MINIMAL BILIOUS DRNG. ABD SOFT, NONTENDER. ABSENT BS.\nGU: UOP GOOD, CLEAR YELLOW. FOLEY PATENT.\nENOD: INITIAL BS 107 THEN AT 1600 87. NO TX NEEDED.\nSOCIAL: DAUGHTER UPDATED ON CONDITION BUT PT NO WANT HER TO VISIT UNITL ETT REMOVED. HAS SPOKEN WITH DR. .\nPLAN: WEAN TO EXTUBATE. ? WEAN LIDO. CONT CURRENT PLAN OF CARE. CONT ASSESS HEMODYNAMICS/RESP STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2126-08-19 00:00:00.000", "description": "Report", "row_id": 1302945, "text": "ADDENDUM: EXTUBATED AT 1830 TO NC. ABG WNL. PT A&OX3. OGT DC'D WITH EXTUBATION. LOW DOSE NTG STARTED FOR SBP >140. INSULIN GTT STARTED FOR BS>130 PER PROTOCOL. PT WITH 4 BEAT RUN VT, MAG GIVEN, REST OF LYTES WNL. LIDOCAINE STILL DECREASED TO 1MG/MIN AT 1800 PER NP. TO CONTINUE ON LIDOCAINE OVERNIGHT. CONTINUE CURRENT PLAN OF CARE\n" }, { "category": "Nursing/other", "chartdate": "2126-08-20 00:00:00.000", "description": "Report", "row_id": 1302946, "text": "nurses note 7pm-7am\nNeuro: A & O x 3, mae, follows commands.\nResp: On 4L/nc with sats>93%, cough is productive for thick yellow sputum. Using IS up to 600. BBS are diminished with scattered rhonchi noted. Ct with mod amt of drtainage noted.\nCV: pt in 1st degree av block, with rare pvc, rate 80-102. SBP 100-150's with nitro gtt on. Hemodynamics stable. Skin warm and dry. PPP.\nGU/GI: taking sips of clliq, bs are hypoactive. Foley to bsd with good huo.\n\nPlan to d/c lido this am, wean nitro to off, wean insulin gtt off. d/c swan, Awaiting cxr this am. ? transfer to floor.\n" } ]

[ { "category": "Radiology", "chartdate": "2193-10-27 00:00:00.000", "description": "P BABYGRAM (ABD ANY SGL VIEW) (74000) PORT", "row_id": 772599, "text": " 9:24 PM\n BABYGRAM (ABD ANY SGL VIEW) () PORT Clip # \n Reason: evaluate bowel gas pattern\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with blood streaks in stool\n REASON FOR THIS EXAMINATION:\n evaluate bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant with blood streaks in stool.\n\n FINDINGS: A supine film of the abdomen demonstrates a normal bowel gas\n pattern. There is no evidence of obstruction or free air. No other abnormality\n is noted.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-28 00:00:00.000", "description": "Report", "row_id": 1916398, "text": "Neonatology Attending\n\"\" remains in RA, open crib cobedding with borther. No a/b. 35+wks corrected.\n\nWt 1795g up 25 on TF150 MM/PE28 with Promod pg>po.\n\nVisibly bloody stool overnight; KUB and exam benign. Stool now guaiac negative.\n\nImp/ age-appropriate feeding immaturity. Possible cow's milk protein allergy since bloody stool was not associated with symptoms or signs of NEC. If so, decision re: feeding change will be complicated as mom's milk supply is limited.\n\nPlan/ continue to monitor cvr status, growth, development & GI status. Will consult with Nutrition re: possible options for diet change if bloody stool recurs.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-28 00:00:00.000", "description": "Report", "row_id": 1916399, "text": "NPN 0700-1900\n\n#4 Alt. in Nutrition\nO: TF=150cc/kg=45cc BM28/PM or PE28/PM Q 4 hrs. Abd. is round, soft with active BS and stable girth. Minimal aspirates, no spits. Infant is alert and acting well. VS are stable. Voiding QS. Passed 2 seedy yellow, somewhat mucousy stools today. 1st stool was guaiac -, the 2nd was guaiac trace. Neither had any visable blood. Feeds given on pump over 1 hr.\nA: ? etiology of bloody stool, possible milk protein allergy in otherwise well appearing infant\nP: Continue close observation for any further s/s feeding intolerance. Feed infant BM as much as possible. Guaiac all stools. Follow daily wts.\n\n#5 Alt. in Parenting\nO: Dad up briefly to drop off breastmilk. Updated. Stated that mom was feeling better and that they both would be up later today to visit with twins.\nA: Involved Dad\nP: informed and support.\n\n#6 Alt. in Development\nO: Maintaining temp in open crib, swaddled, positioned on side or supine, co-bedding with sibling. Boundaries in place. Not waking for feeds, but alert with cares. Sucks well on pacifier. No spells.\nA: Appropriate behaviors for GA\nP: Continue to support developmental needs.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-29 00:00:00.000", "description": "Report", "row_id": 1916400, "text": "4. F/N: O: Infant is on 150cc/k/d of 28cal BM/PE + promod,\ndelivered q 4 hours mostly via gavage over one hour q feed.\nAbd is benign, no spits, min asps. He is voiding and\nstooling g- stools. He bottled 20cc w/ the yellow nipple at\nthe last care time taking a few good sucks but tending to\ndribble. He gained 45g. D/s was 82. Labs are pnd at this\nwriting. A: Tol feeds, mostly gavage, gaining wt. g- stools.\nP: Continue to monitor. Attempt bottling at least q shift.\nCheck results of labs.\n\n5. : No contact from the family so far this shift.\n\n6. G/d: O: Infant is alert w/ cares, waking occasionally for\nfeeds. He is co-bedding w/ his brother. is stable in\nthe open crib and infant sucks vigorously on a binkie. A/P:\nContinue to support infant needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-29 00:00:00.000", "description": "Report", "row_id": 1916401, "text": "Neonatology- Physical Exam\n\nInfant remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Pleaserefer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-31 00:00:00.000", "description": "Report", "row_id": 1916413, "text": "Neonatology ATtending\n\"\" remains in RA, open crib. 17 do, 36+ wks corrected. No a/b.\n\nwt 1880g up 5 on TF150 MM/PE 28 with Promod pg>po; voiding, stooling (stool trace guaiac positive this am but no gross blood)\n\nMeds Fe\n\nBUN today 25 (was 28 2 days ago)\n\nImp/ approaching term corrected, working on PO feeding skills. History of grossly bloody stool 4 days ago but asymptomatic - presumed cow milk protein allergy - getting some PE 28 but mostly mom's milk now, only trace heme positive. Persistently high BUN on Promod.\n\nPlan/ continue to follow cvr status, growth & development. Hold Promod for a few days, recheck BUN . Consider trial elemental formula if bloody stool recurs.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-31 00:00:00.000", "description": "Report", "row_id": 1916414, "text": "NPN 0700-1900\n\n\n#4 O: TF= 150cc/kg/d. Infant taking 47cc's of PE28/BM28\n(promod on hold for now for a few days until recheck of\nBUN). Feeding q 4h via po/pg. Bottled entire volume x1 this\nshift. Abdomen benign; voiding and stooling slightly guaic +\nstool. No aspirates, one small spit. AG 25.5-26.5cm. A:\nTolerating feeds. P: Cont to monitor and encourage po feeds.\nRecheck BUN .\n\n#5 O: No contact from as yet this shift. Family\nmeeting to be held at 1600. A/P: Cont to support and update.\n\n#6 O: Infant maintaining temp in oac; cobedding with twin.\nAwake and alert with cares; sleeping well between. Swaddled\nin blanket; brings hands to face for comfort. A: AGA. P:\nCont to support development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-01 00:00:00.000", "description": "Report", "row_id": 1916415, "text": "Npn 2300-0700\n\n\n\n4: FEN\n\nCurrent weight1900 gms up 20gms. Total fluids remain at\n1500cc/kilo/day of bm 28/pe 28. Alternating po/pg.\nTolerating feeds well. Thus far min aspirates and no spits.\nVoiding and had one hem neg stool thus far. Girths stable.\nabd exam benign. No loops.\n\n5: Parenting:\n\nNo contact thus far.\n\n6: Alt G/D\n\nTemps stable in an open crib. Alert and active with cares.\nSleeps well inbetween. Sucks on pacifier and brings hands to\nface AGA. Continues to be co-bedded with sibling\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-01 00:00:00.000", "description": "Report", "row_id": 1916416, "text": "Neonatology Attending\n is 18d0, 36+ wks corrected. Remains in RA, open crib cobedding with brother. a/b.\n\nWt 1900g up 20 on TF150 MM/PE28 po/pg - taking full bottles qo feed.\n\nMeds Fe\n\nImp/ approaching term corrected, working on Po feeding skills.\n\nPlan/ continue to monitor cvr status, growth & development. D/C planning in progress pending further maturation of po feeding abilities.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-01 00:00:00.000", "description": "Report", "row_id": 1916417, "text": "NPN: See flowsheet for obj data not mentioned\n\n\n4. FEN: Remains on 150 cc/k/d of BM28 or PE28 = 48 cc q 4\nhours alternating po/pg. Took 36 cc po before becoming too\nsleepy to eat, rest of feed gavaged. Promod remains on hold\ndue to elevated BUN. Voiding and stooling. Stool heme (-).\nNo spits so far this shift. Plan: continue current feeding\nplan\n\n5. Parent: No contact from so far this shift. Plan:\nContinue to promote family bonding and parental education\nre: infant care geared towards discharge.\n\n6. G/D: Temp remains stable in OAC, co-bedding with sibling.\nDoes not wake for cares but A/A with cares. does become\nsleepy by end of po feeds. Sleeps between cares. Plan:\nContinue to provide age appropriate cares.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-14 00:00:00.000", "description": "Report", "row_id": 1916334, "text": "Admission Note\n\n\nTwin #2 admitted to NICU at 1230 today, weight 1725 on\nadmission. Approx gestational age is 33 6/7 weeks. Twin #2\ndelivered breach presentation, no molding, occiput or\ncephelohematoma present. Bruising on extremities noted.\nRectal temp cool initially, 96.5, warmed to 99.2 after\nseveral minutes under radiant warmer.\nResp: Infant tachypnic, breathing 80-100 breaths per\nminute. Lung sounds diminished, slight subcostal\nretractions observed, sats maintained >95% in RA. No oxygen\nsupport needed at this time, will continue to monitor.\nCV: No audible murmer, HR 150-180, pulses palpable in\nextremities, skin pink and warm. BP low initially 64/22\n(32) increased to 68/24 (36).\nFEN: Glucose on admission was 50. IV started in right hand,\nD10 currently running at 80 cc/kg/day. Infant remains NPO,\nabdomen soft, active bowel sounds. No stool this shift.\nID: CBC and blood cultures sent - see lab section for\nresults. Amp and Gent given times one. Pt. sleepy, not\nawake and alert. Will continue to monitor.\nSocial: FOC in to see twins this afternoon, Twin #2 named\n. FOC updated on infant's condition, returned to L&D\nto be with .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-14 00:00:00.000", "description": "Report", "row_id": 1916335, "text": "1 Respiratory Distress\n2 Cardiovascular\n3 ID\n4 FEN\n5 Parenting\n\nREVISIONS TO PATHWAY:\n\n 1 Respiratory Distress; added\n Start date: \n 2 Cardiovascular; added\n Start date: \n 3 ID; added\n Start date: \n 4 FEN; added\n Start date: \n 5 Parenting; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-15 00:00:00.000", "description": "Report", "row_id": 1916336, "text": "npn 1900-0700\n\n\n\n1: resp\n\ninfant remains on ra. sats 95% and greater with no dsats.\nresp rate 50-100's. Np aware. No spells. inter/sub\nretractions. no grunting and no nasal flaring noted.\nlung sounds clear and equal. Will continue to monitor for\nchanges in resp status.\n\n2: CV\n\nno murmur. hr 140-160's. bp means > 39. pink and well\nperfused. pulses wnl. Will continue to monitor\ncardiovascular status.\n\n3: ID\n\ninfant remains on amp and gent for 48hr rule out. no s/s of\ninfection noted. Will continue to monitor for changes.\nblood culture pending.\n\n4: FEN\n\nBW 1725 gms. total fluids remain at 80cc/kilo/day of D10 w.\ninfant npo. abd is soft with no loops. voiding qs no stool\nthus far. dstick stable at 78. ivf running well via piv.\n\n5: Parenting\n\nNo contact thus far from parents\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-15 00:00:00.000", "description": "Report", "row_id": 1916337, "text": "Neonatology Attending\nDOL 1\n\nRemains in room air with no significant distress today after resolution of mild tachypnea overnight. No apnea/bradycardia.\n\nNo murmur. BP 55/38 (43).\n\nBW 1725, on TFI 80 cc/kg/day. Urine output 2.7 cc/kg/hr in the past 12 hours. D-stick 83. Abdomen benign.\n\nOn ampicillin and gentamicin. WBC 6.6 (28 neut 4 bands).\n\nA&P\nPreterm infant with resolved transitional respirations. We will start trophic feeds today. Antibiotics may be discontinued after 48 hours course provided culture remains negative. Serum electrolytes and bilirubin will be checked at 24 hours.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-05 00:00:00.000", "description": "Report", "row_id": 1916430, "text": "NPN NOCS\n\n\n4. O: Wt up 35gms. TF at min 150cc/kg of PE/BM28. All po's.\nTook in 166cc/kg yesterday. Nutrition labs pending. Voiding\nand stooling. No spits. A: Good po's/gaining wt. P: Continue\nwith plan and monitor.\n\n5. No contact from thus far this shift.\n\n6. O: and active. Waking for feedings. Temp stable in\nopen crib. Cobedding with sibling. Passed carseat test. A:\nAGA. P: Continue to support dev. needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-05 00:00:00.000", "description": "Report", "row_id": 1916431, "text": "Neonatology Attending Note\nDay 22\n\nRA. RR40-50s. No AOP. Lungs cl and =. no rtxns. h/o int soft murmur. Weight , up 35. Min 150 BM/PE28. Intake 166. Nl voiding and stooling. In open crib.\n\nPlan:\n- Good intakes. Weight gain on low side will try to go to 26 cals for home, however, if weight gain not adequate will need to return to 28 cals.\n- Continue discharge planning and teaching. If all goes well, hope to go home w/ sib on Thursday.\n- Will plan a circumcision per parent's request.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-05 00:00:00.000", "description": "Report", "row_id": 1916432, "text": "Neonatal NP-Exam\n\nsee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. nl S1S2, grade II/Vi murmur audible. and well perfused. aBd benign, no HSm. active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-05 00:00:00.000", "description": "Report", "row_id": 1916433, "text": "Npn 0700-1900\n\n\n\n1; FEN\n\ntotal fluids remain at a min of 150cc/kilo/day. Feeds are\ncurrently of Bm 26 or Neosure 26cals. Plan to use cornoil\nrather than mct when family brings in the cornoil. Infant\nbottling at all feeds. Thus far this shift infant has taken\n45 cc at 9am and 50cc at 1pm. tolerating feeds well. infant\nhad one small spit thus far. Voiding and stooling hem neg\nstool. Abd is soft and round with no loops. Plan to send\ninfant home on 26cals if gaining weight. Will continue to\nencourge all po feeds.\n\n5: Parenting\n\nNo contact thus far from .\n\n6: G/D\n\nTemps stable in an open crib. Infant co-bedded with twin.\n and active with cares. Waking for feeding. Infant\nbringing hands to mouth and sucking on pacifier. Infant does\nwake at times inbetween cares. Settles easily with pacifier\nand swaddling.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-05 00:00:00.000", "description": "Report", "row_id": 1916434, "text": "Npn 0700-1900\nDev; Hep B vaccine given. Consent in chart. Ob aware that circ needed prior to discharge this week. Possible d/c on thursday.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-06 00:00:00.000", "description": "Report", "row_id": 1916435, "text": "NPN NOCS\n\n\n4. O: Wt unchanged. TF at min 150cc/kg of Neosure 26.\nBottling well. Took in 153cc/kg yesterday. Voiding and\nstooling. No spits. Abd. benign. A: Good po intake. P:\nContinue with plan.\n\n5. No contact from this shift.\n\n6. O: and active. Waking for feedings. Temp stable in\nopen crib-cobedding with sibling. Loves pacifier. A: AGA. P:\nContinue to support dev. needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-06 00:00:00.000", "description": "Report", "row_id": 1916436, "text": "Neonatology Attending\nDay 23\nCGA 37 1\n\nRA. RR40-60s. Cl and =. No retractions. No A&Bs. Soft, int murmur. HR 150-170s. /pale. Well perfused. Wt , no change. Min 150 Neosure 26/BM26 all po. Total intake 153. In open crib.\n\nPlan:\nProgressing well. Good po intakes. Disappointed about lack of weight gain.\n - complete parent teaching\n - circ planned for this pm\n - con't po, if fails to gain weight will need to d/c to home on 28 cals\n - still planning on discharge in am\n" }, { "category": "Nursing/other", "chartdate": "2193-10-16 00:00:00.000", "description": "Report", "row_id": 1916345, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, RRR, . Abdomen soft, non-distended with active bowel sounds, no HSM. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-17 00:00:00.000", "description": "Report", "row_id": 1916346, "text": "Neonatology Attending\n\nDay 3\n\nRemains in RA. RR 30-50s. No bradycardia. Sa-O2 99-100%. BP mean 45. Weight 1675 gms (-15). TF at 100 cc/kg/d. Enteral feeds at 70 cc/kg/d. IV dextrose at 30 cc/kg/d. No po intake. Stable abdominal girth. Bilirubin 4.6/0.3. Newborn screen sent. Parents up to date.\n\nAdequate breathing control most recently. Monitoring closely. Advancing total fluids to 120 cc/kg/d. Continuing to advance enteral feeds by 20 cc/kg twice daily. Following bilirubin.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-17 00:00:00.000", "description": "Report", "row_id": 1916347, "text": "NNP Physical Exam\n\nPE: , AFOF, sutures slightly overriding, breath sounds clear/equal with mild intercostal retracting, no murmur, abd soft, nondistended, bowel sounds active, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-17 00:00:00.000", "description": "Report", "row_id": 1916348, "text": "NPN DAYS\n\n\nALT IN RESP:REMAINS IN RA, MAINTAINS O2 SATS IN HIGH 90'S TO\n100%. LUNGS CLEAR, RR 40'S WITH MILD SUBCOASTAL RETRACTIONS.\nNO EPISODES OF APNEA OR BRADYCARDIA OR DESATS. CONTINUE TO\nMONITOR FOR SPELLS.\n\nCV:HR 130-140'S. NO MURMUR. BP 67/29 45. NO EVIDENCE OF\nCARDIAC COMPROMISE. PROBLEM RESOLVED. CONTINUE TO MONITOR\nFOR ANY CHANGES IN EXAM.\n\nID:BLD CX NEG. ANTIBXS D/C'ED YESTERDAY AT 48HRS. PROBLEM\nRESOLVED. CONTINUE TO MONITOR FOR S/S OF INFECTION.\n\nALT IN NUTRITION R/ :TF 120CC/K/D. FEEDS CURRENTLY AT\n90CC/K/D OF PE20, 26CC Q4HRS VIA GAVAGE. INCREASING FEEDS\n20CC/K/D AT 12AM AND 12PM. ABD EXAM BENIGN, NO LOOPS, NO\nSPITS. GIRTH 20. ASP. 0.4-1.2CC. NO STOOL TODAY. UOP\n3.7CC/K/HR FOR THE PAST 12HRS. D/S 83. IVF OF D10W WITH 2MEQ\nNACL AND 1MEQ KCL INFUSING AT 30CC/K/D. IV INFILTRATED THIS\nAFTERNOON. NEW IV PLACED IN RIGHT FOOT, AND IVF INFUSING\nWITHOUT INCIDENCE. CONTINUE CURRENT FEEDING PLAN. MONITOR\nFOR ANY FEEDING INTOLERANCE.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. SWADDLED. MAINTAINS TEMP IN\nAIR CONTROLLED ISOLETTE. SUCKS ON PACIFER BRIEFLY. CONTINUE\nDEVELOPMENTAL CARES.\n\nALT IN PARENTING:DAD CALLED FOR UPDATE THIS MORNING. PARENTS\nIN TO VISIT AT 5PM. ENCOURAGED PARENTS TO VISIT DURING CARE\nTIMES. UPDATED A T BEDSIDE. MOM HELD BABY FOR 1HR. CONTINUE\nTO SUPPORT AND UPDATE. GAVE MOM PHONE NUMBER OF LACATATION\nCONSULT. SHE IS PUMPING BUT NOT GETTING ANY BM YET.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-18 00:00:00.000", "description": "Report", "row_id": 1916349, "text": "NPN 1900-0700\n\n\n1. O: Infant remains in room air. O2 sats 100%. RR 40's with\nmild retractions noted. Ls clear bilaterally. No A&B's\nnoted thus far. A: Stable P: Continue to assess.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-20 00:00:00.000", "description": "Report", "row_id": 1916361, "text": "NPN 0700-1900\n\n\nRESP: Remains in room air with sats 98-100%. RR 40-60's.\nBreath sounds are clear and equal. No retractions. No\napnea or bradycardia.\nA/P: Will cont to follow closely.\n\nF&N: TF- 150cc/kg/d. Calories were increased to 22 today.\nInfant had one small spit prior to increasing cals. NG\nfeeds are delivered over 45minutes and he has had no further\nspits. Abd is round and soft with active bowel sounds and\nno loops. AG-20.5-21cm. Voiding and stooling.\nA/P: Monitor spits/tolerance to feeds/incr. cals\n\n: Mom and sister int o visit. Mom and sister both\nheld infant after receiving a bath . Updated Mom at the\nbedside. She plans to visit tomorrow at 4pm.\n\nDEV: Temp is stable while swaddled in heated isolette-\nisolette not weaned this shift. Infant is alert and active\nwith cares. He sleeps well between cares. Did not bottle\nthis shift.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-20 00:00:00.000", "description": "Report", "row_id": 1916362, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, . Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-21 00:00:00.000", "description": "Report", "row_id": 1916363, "text": "NPN 1900-0700\n\n\n1. O: Ls clear. O2 sats 99-100% RA. RR 40-60's. No spells.\nA: Resp status stable. P: Cont to monitor resp status.\n\n4. O: Wt 1675 gms , up5. Tf 150cc/kg of BM/PE 22 po/ngt. Pt\ntook 15cc po at 2400 care. 1 small spit. Min asp. AG20.5-21\ncm. Voiding an dstooling G-. A: Tol feeds. P: Cont to\nmonitor wt, abd, and tol of feeds.\n\n5. No contact from family thus far this shift.\n\n6. O: Temp stable swaddled in air isolette. Decreased box\nX1. Alert and active with care. Occ sucking on pacifier.\nA/P: Cont to monitor temp. Cont to cluster care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-21 00:00:00.000", "description": "Report", "row_id": 1916364, "text": "Neonatology Attending\n\nDay 6\n\nRemains in RA. RR 30-40s. HR 130-160s. , well-perfused. BP mean 39. Weight 1675 gms (+50). TF at 150 cc/kg/d- PE/BM 22. Taking one po feed per shift. Took 15 cc yesterday. Benign abdomen. Stable temperature in incubator. Alert and active with cares.\n\nAdequate breathing control most recently. Will continue to monitor cardio-respiratory status closely. Advancing feeds to 24 cals/oz. Following feeding tolerance. Family up to date.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-21 00:00:00.000", "description": "Report", "row_id": 1916365, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-21 00:00:00.000", "description": "Report", "row_id": 1916366, "text": "NPN 0700-1900\n\n\n#1 Resp\nO: Infant remains in RA. Resp rate=30-60's. O2 sats=98-100%.\nLS are clr/=. No spells thus far. A: Stable in RA P:\nContinue to monitor.\n\n#4 FEN\nO: TF=150cc/kg/day of BM/PE24, 44cc q 4hr gavaged over\n45min. Plan to PO at 4pm. No spits. Aspirates=0.0-1.0cc.\nAG=21-22cm. V/S, heme neg. Abdomen benign. Active bowel\nsounds. A: Tolerating feeds P: Continue to monitor.\n\n#5 Parenting\nO: Mom plans to be in for the 4pm cares. A: unable to assess\nat this time.\n\n#6 G&D\nO: Infant remains in Air Isolette, weaned temp x1. Swaddled.\nTemp stable. A/A w/ cares. Sleeps well in between cares.\nSucks on pacifier. A: AGA P: Continue to support and\nmonitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-23 00:00:00.000", "description": "Report", "row_id": 1916374, "text": "NPN 0700-1900\n\n\n#4 FEN\nO: TF=150cc/kg/day of BM/PE26 w/promod, 44cc q4hr gavaged\nover 1hr. Plan to PO feed at 4pm. 1 small spit. V/S, heme\nneg. Minimal aspirates. AG=23.5cm. Abdomen benign. Active\nbowel sounds. A: Tolerating feeds P: Continue to monitor and\nencourage PO feeds.\n\n#5 Parenting\nO: No contact w/ thus far. A: Unable to assess at\nthis time.\n\n#6 G&D\nO: Infant remains in Air Isolette. Weaned isolette temp at\n8am. Temp is stable. Swaddled. A/A w/ cares. Sleeps well in\nbetween cares. A: AGA P: Continue to monitor and support\nG&D.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-23 00:00:00.000", "description": "Report", "row_id": 1916375, "text": "Clinical Nutrition:\nO:\n35 wks CGA, BB now on DoL #9\nWt: 1700g (+5g)-(~10th%ile); currently 25g below birth wt.\nLN: 42.5cm (10-25th%ile)\nHC: 31cm (25-50th%ile)\nLabs: none recent\nMeds: Iron (~4.4-4.5 mg/kg/day from feeds & supplement)\nNutrition: BM/PE26 w/promod @ 150 cc/kg/day\nProjected 24 hr intake: ~150 cc/kg= ~130 kcals/kg & ~4.1-4.4 g/kg of protein\nGI: benign\n\nA/goals:\nTolerating feeds well w/ occasional small spits. Voiding & stooling. Advancing feeds Qday per NICU protocol, adding promod today to provide optimal protein in feeds. Working on PO feeding skills, took ~10cc o/n. Nutrition labs due on Monday. is still below birth wt. but has gained wt. the last 5 consecutive days. Goal wt. gain: ~15 g/kg/day once @ full feeds. Suggest advancing feeds to 28Kcals/oz- hold there & monitor growth trends. Will cont. to follow w/team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-23 00:00:00.000", "description": "Report", "row_id": 1916376, "text": "NPN DAYS\nAgree with above note by coworker .\n" }, { "category": "Nursing/other", "chartdate": "2193-10-24 00:00:00.000", "description": "Report", "row_id": 1916377, "text": "Co-Worker Note: \n\n7 Alt in CV\n\n4. FEN: O: Currentwt. up 35g to 1735g. On TF of 150cc/k/d of\nBM/PE26 with promod= 44cc q4 hours. Abdomen exam benign.\nV/S, hem -. +BS. No loops. Min asps. Girth stable. Bottled\n5cc at 0000 with yellow nipple. See flowsheet. A: TF P:\nContinue current.\n\n5. PAR: O: No contact thus far. See flowsheet. A: Loving\nfamily. P: Support and educate.\n\n6. G&D: O: Pt. remains swaddled in low air control isolette,\ntemps stable. Weaning isolette as tol. Awake and alert with\ncares, Sleeping well between. See flowsheet. A: AGA P:\nSupport G&D.\n\n7. CV: O: Soft intermit murmur noted this evening. Rn to and\nNNP aware. Perif pulses wnl. Good cap refill. See flowsheet.\nA: Alt in CV. P: Monitor.\n\nREVISIONS TO PATHWAY:\n\n 7 Alt in CV; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-24 00:00:00.000", "description": "Report", "row_id": 1916378, "text": "Agree with above note with additions:\n7. O: Soft murmur heard x2 with exam. Pulses are full, not bounding. Color is , well perfused. Sao2 in high 90's consistantly. BP stable. NNP aware.a: New murmur auscultated, no compromise noted. P: Monitor.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-24 00:00:00.000", "description": "Report", "row_id": 1916379, "text": "NEonatology-NNP PRogress Note\n\n remains in his isolette, in room air, bbs cl=, rrr s1s2no murmur, abd soft, nontender, V&S, cord drying, afso, active with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2193-10-24 00:00:00.000", "description": "Report", "row_id": 1916380, "text": "Neonatology Attending\n\"\" is 10 do, 35 wks today. Remains in RA, isolette. no a/b.\n\nWt 1735 up 35 on TF150 PE/MM26 with Promod pg>po. Voiding, stooling.\n\nMeds Fe\n\nImp/ age-appropriate immaturity of feeding and thermoregulation. Growth improving on increased caloric density.\n\nPlan/ continue to monitor cvr status, growth & Development. Increasing to 28cal/oz feeds today.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-27 00:00:00.000", "description": "Report", "row_id": 1916392, "text": "Neonatology Attending\n\nDay 13\n\nRemains in RA. Clear breath sounds. RR 30-40s. No retractions. HR 130-180s. No murmur. Weight 1770 gms (unchanged). TF at 150 cc/kg/d. On BM/PE 28 with Promod. Offered occasional bottles with maximum intact 15 cc. Benign abdomen. Moved to open crib and now co-bedding. Waking for feeds. in daily.\n\nAdequate breathing control. Monitoring closely. Gaining weight well overall. Tolerating feeds. No changes anticipated for today.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-27 00:00:00.000", "description": "Report", "row_id": 1916393, "text": "Progress Note 0700-1900\nI have read and agree with the above note written by .\n" }, { "category": "Nursing/other", "chartdate": "2193-10-27 00:00:00.000", "description": "Report", "row_id": 1916394, "text": "Progress Note 0700-1900\n\n\n4. FEN: O: TF 150cc/kg/d of BM/PE28+Promod po/pg. Offering\nbottle qshift or as interested. Bottled 22cc @ 1230.\nOtherwise gavaging 44cc over 1 hour for spits. Abd exam\nbenign, +BS, no loops. A/G . Voiding and\nstooling. Sm spit x1. Min asps. A: Tolerating feeds. P: Cont\nto monitor.\n\n5. : No contact w/ so far this shift.\n\n6. DEV: O: is alert/active with cares. Moved into\nOAC w/twin on nights. Temps stable swaddled w/hat. Occ wakes\nfor feeds. Sleeps well b/w cares. Roots and sucks on\npacifier. A: AGA. P: Cont to support dev needs.\n\nsee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-28 00:00:00.000", "description": "Report", "row_id": 1916395, "text": "NPN 1900-0700\n\n\n#4 FEN\nO: TF=150cc/kg/day of BM/Pe28 w/promod, 45cc q4hr gavaged\nover 1hr. Infant took 32cc at 12:30am. No spits. Minimal\naspirates. V/S, frank blood found in stool at 8:30pm. Infant\nwas examined by and X-ray was normal, continued feeds.\nTrace positive stool at 12:30am, and RN aware. Abdomen\nbenign. Active bowel sounds. AG=22cm. Weight=1.795kg, up\n25grams. A: Tolerating feeds P: Continue to monitor and\nencourage PO feeds.\n\n#5 O: Dad came in to bring BM. Mom admitted to hospital for\npossible infection of the uterus lining. A: Unable to assess\nat this time.\n\n#6 O: Infant remains in OAc, cobedding w/ brother. Swaddled\nw/ hat on. Temp stable. A/A w/ cares. Occasionally wakes for\nfeeds. sleeps well in between cares. Sucks on pacifier. A:\nAGA P: Continue to monitor and support G&D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-28 00:00:00.000", "description": "Report", "row_id": 1916396, "text": "NPN\n\n\nAdendum:\n\nThis Rn has examined infant and agree's with \nnote. Will cont to monitor stools.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-28 00:00:00.000", "description": "Report", "row_id": 1916397, "text": "Neonatology- Physical Exam\n\nInfant remains in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and fequal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, round, +bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-30 00:00:00.000", "description": "Report", "row_id": 1916406, "text": "Clinical Nutrition:\nO:\n36 wks CGA, BB now on DoL #16\nWt: 1875g (+35g)-(<10th%ile); gained an average of 13 g/kg/day over the last week.\nLN: 43cm (42.5)-(10-25th%ile)\nHC: 32cm (31)-(25-50th%ile)\nLabs: noted\nMeds: Iron (~4.2 mg/kg/day from feeds & supplement) & vit E\nNutrition: BM/PE28 w/ promod @ 150 cc/kg/day\n3 day average intake: ~149cc/kg= ~139 kcals/kg & ~4.1-4.4 g/kg of protein\nGI: g- stools for >24hrs\n\nA/goals:\nTolerating feeds well, minimal spits/aspirates noted. Feedings are gavaged over one hour. Previously passing g+ stools, none recently. voiding & stooling. Wt gain just below goal range, but just reached goal volume feeds; suspect will improve over the next week. Nutrition labs checked yesterday, slightly elevated BUN to repeat tomorrow morning. Continues on Iron & vit E. Will cont. to follow w/team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-30 00:00:00.000", "description": "Report", "row_id": 1916407, "text": "Neonatology- PRogress Note\n\n in his big boy crib, cobedding with his brother, in room air, bbs cl=, rrr soft systolyc murmur audible, pulses 2+=, abd soft, nontender, V&S, afso, active with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2193-10-30 00:00:00.000", "description": "Report", "row_id": 1916408, "text": "NPN 0700-\n\n\n4. TF 150/k/d of BM28PM/PE28PM=47cc Q4hr. Abd benign.\nVoiding and heme negative stool x1. Able to bottle 40-47cc\nthus far. Tolerating feeds without aspirates/emesis. Cont\nto work up on PO feeds as tolerated.\n\n5. No contact thus far.\n\n6. Temp stable swaddled in OC. Infant cobedding with\nbrother. Awakes at times for feeds, alert. Resting well\ninbetween cares. MAE, brings hands to face. Cont to\npromote G&D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-30 00:00:00.000", "description": "Report", "row_id": 1916409, "text": "NPN addendum\n\n\n5. in for a brief visit and updated on plan of\ncare. Family meeting planned for at 1600- team aware.\nCont to support and update .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-31 00:00:00.000", "description": "Report", "row_id": 1916410, "text": "Npn Nights\n\n\n4) Fen: TF 150/k/d of Bm28 with PM. Feeding 47cc po/pg QOF.\n Pg over 1h, po fair taking most of feeding. No spits, no\naspirates. Tol feeds well. Abd benign. Voiding and\nstooling. Weight up 5 grams. Plan: cont QOF po feeds.\nCont to monitor. BUN pending.\n5) Parenting: No contact this shift. Plan: cont support and\nupdates. Family meeting today.\n6) G/D: Temp stable in open, co-bedding crib. Infant awakes\nfor feedings and calms easily with a pacifier. Appropriate\nfor GA. Plan: cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-31 00:00:00.000", "description": "Report", "row_id": 1916411, "text": "Neonatology- Physical Exam\n\nInfant remains in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-31 00:00:00.000", "description": "Report", "row_id": 1916412, "text": "Neonatology- Physical Exam\n\nFamily meeting today with . Discussed feeding issues, apnea of prematuriy, discharge criteria. Please refer to family meeting checklist.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-26 00:00:00.000", "description": "Report", "row_id": 1916386, "text": "npn 1900-0700\n\n\n\n4: FEN\n\nCurrent weight 1770gms up 45gms. Total fluids remain at\n150cc/kilo/day of pe28/bm28 with prom. Tolerating feeds\nwell. abd soft. girths stable. no loops. voiding and\nstooling. Stool hem neg. no spits and min aspirates. Po's\n15cc at 1230. Plan to contiue to encourage po feeds.\n\n5: parenting\n\nMom and dad in for visit at 8pm. Mom changed diaper and\nchecked the temp. Mom held infant. infants sister also in\nfor visit. Family very loving and invested. Hels infant for\nshort period. updated at the bedside. Plan to be\nback for visit at 1230 afternoon.\n\n6: Dev\n\ntemps stable in an open crib. Alert and active with cares.\nwoke for feeds thus far this shift. suckes vigourously on\npacifer and brings hands to face.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-26 00:00:00.000", "description": "Report", "row_id": 1916387, "text": "NNP Physical Exam\n\nPE: , jaundiced, AFOF, breath sounds clear/equal with easy wOB, very soft murmur LSB, +2/= pulses, abd soft, non distended, active bowel sounds, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-26 00:00:00.000", "description": "Report", "row_id": 1916388, "text": "Neonatology Attending\n\nDOL 12 CGA 35 4/7 weeks\n\nStable in RA. No A/B.\n\nBP 69/41 mean 45\n\nOn 150 cc/kg/d PE 28 with promod taking ~ po. Voiding. Stooling. Wt 1770 grams (up 45).\n\n visiting and up to date.\n\nA: Stable. Needs to learn to feed, but improving.\n\nP: Monitor\n Encourage po as tolerated\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-03 00:00:00.000", "description": "Report", "row_id": 1916424, "text": "NPN 0700-1900\n\n\n#4 O: TF 150 cc/kg/d. Taking 49cc q4h of PE 28, bottled x2\ntaking entire volume. Abdomen benign. AG 23cm. No aspirates,\nor spits. Voiding and stooling guiac negative, seedy\nstool.BUN level 18, infant remains off promod.\nA: Tolerating feeding.\nP: Encourage po feeding.\n\n#5 O: No contact with family.\nA/P: Continue to offer support.\n\n#6 O: Infant maintaining temp. In OAC cobedding with\nsibling. Awake and lert with care. Sleeping in between\ncares. Sucking vigorously on pacifier.\nA: AGA.\nP: Continue to support development.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-03 00:00:00.000", "description": "Report", "row_id": 1916425, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equal. Nl S1S2, grade II/Vi murmur audible. and wll perfused. aBd benign, no HSm. active bowel soudns.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-04 00:00:00.000", "description": "Report", "row_id": 1916426, "text": "Nursing Progress Note 1900-0700\n\n\nF/E/N:Infant cont's on TF 150cc's/kg/day.Rec. 49 cc's of PE\n28 q 4 hrs.Infant bottling 47-60cc's with a yellow\nnipple.Weight=1.970kg up 20 grams.Abd. soft,pos bs,no loops\nor spits.Minimal aspirates.Girth=24-25.5.Infant voiding and\nstooling.A:Stable P:Cont. to assess tolerance of feeds and\nmonitor weight gain.\n\nParenting:No contact from thus far.A/P:Cont. to\nsupport,update and educate.\n\n\nG/D:AFSF.Infant remains active and with cares.Sleeping\nwell b/t cares.Waking prior to feeds.Infant co-bedding with\nsibling.Temp. remains stable in open crib.Infant swaddled\nwith nested boundaries.Infant sucking intermitently on\npacifier,bringing hands to face and mouth.A:AGA P:Cont. to\nsupport growth and dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-04 00:00:00.000", "description": "Report", "row_id": 1916427, "text": "Neonatology Attending Note\nDay 21\nCGA 36 \n\n\nRA. RR30-50s. No AOP. HR 140-150s. +Int soft murmur. 73/37, 48. Pale/. Wt , up 20 gms. TF 150 cc/k/day BM/PE 28 mostly po past 24 hours. Tolerating well. Nl voiding and stooling (decreasing guaiac positive stools). In open crib.\n\nGrowing preterm infant.\n- Evaluate murmur on exam today.\n- Encourage po skills.\n- Still below 10%, will keep on high calorie nutrition.\n- Check nutrition labs in am.\n- Approaching discharge readiness will discuss with family.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-04 00:00:00.000", "description": "Report", "row_id": 1916428, "text": "NPN 0700-1900\n\n\n#4 O: TF 150cc/kg/d. Inant taking 49cc of PE 28 q4h po. NG\ntube taken out this am. Abdomen benign, no spits. Voiding\nand stooling. Team would like infant to bottle all feeds x48\nhrs and gaining weight before discharge. Possible discharge\nas early as Wednesday.\nA: Tolerating po feeds.\nP: Encourage po feeds.\n\n#5 O: not in to visit. Attempted to reach by phone\nregarding discharge teaching. not at home.\nA: Unable to assess.\nP: Continue discharge teaching.\n\n#6 O: Infant maintaining temp. cobedding in OAC with\nsibling. Awake and with cares, sleeping in between.\nsucking vigorously on pacifier. EIP contact today by RN.\n VNA contact but unable to take infants information\nuntil definite discharge date.\nA: AGA\nP: Continue to support development.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-04 00:00:00.000", "description": "Report", "row_id": 1916429, "text": "Addendum:\nBoth in to visit at 1715. Please see twin #1 addendum note for details of d/c teaching.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-26 00:00:00.000", "description": "Report", "row_id": 1916389, "text": "NPN: SEE FLOWSHEET FOR OBJ DATA NOT MENTIONED.\n\n\n4. FEN: WT UP TO 1770 GRAMS. REMAINS ON 150 CC/K/D OF PE 28\nWITH PROMOD. TOLERATING FEEDS WELL WITH SCANT RESIDUALS AND\nNO SPITS SO FAR. GIRTHS STABLE, VOIDING AND STOOLING LARGE\nSEEDY YELLOW STOOLS. TAKING SMALL AMOUNT (~10CC) OF FEED PO\nWITH POOR COORDINATION. PLAN: CONTINUE CURRENT FEEDING PLAN\nAND ADVANCE PO FEEDS AS TOLERATED.\n\n5. PARENTING: ARRIVED BETWEEN CARES. MOTHER BROUGHT\nIN BREASTMILK. ENCOURAGED TO COME AT TIMES OF CARES\nSO THAT THEY COULD PROVIDE CARES AND WORK ON EDUCATION.\nPLAN: ENCOURAGE TO PARTICIPATE IN CARES AND AND WORK\nWITH THEM ON EDUCATION GEARED TOWARDS DISCHARGE. CONTINUE TO\nPROMOTE FAMILY BONDING.\n\n6: DEV: TEMP STABLE IN LOW-TEMP AIR-CONTROLLED ISOLETTE.\nBRINGS HANDS TO MOUTH TO COMFORT SELF. PLAN: CONTINUE TO\nPROVIDE AGE APPROPRIATE CARES.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-27 00:00:00.000", "description": "Report", "row_id": 1916390, "text": "npn 1900-0700\n\n\n\n4: FEN\n\nCurrent weight 1770 no change from last night. Total fluids\nremain at 150cc/kilo/day of bm/pe 28 with prom. Tolerating\nfeeds well. Min asp and no spits. Voiding and stooling with\neach diaper change. Bottle fed at 0030. infant took 10cc and\nthen fell asleep. Infant continue to be uncoordinated with\nfeds. Plan to continue to encourage po intake. abd exam\nbenign. girths stable. no loops.\n\n5; No contact with thus far this shift.\n\n\n6: Dev\n\ntemps stable in an air heated isolette. Isollete turned off\nat 0030. Temps remain stable. Plan to co-bed with twin if\ntemp stable at 500. Alert and active with cares. brings\nhands to face and sucks on pacifier.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-27 00:00:00.000", "description": "Report", "row_id": 1916391, "text": "npn 1900-0700\nisolette turned off at 830 pm.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-29 00:00:00.000", "description": "Report", "row_id": 1916402, "text": "Neonatology Attending\n\"\" is 15do, 36wks corrected. Remains in RA, open crib cobedding with \"Will\"; no a/b. Intermittent soft murmur.\n\nWt 1840 up 45 on TF150 MM28/PE28 with Promod pg>po; took 20cc po last pm. More awake/alert than his brother with feeds. Stools have been heme negative past 24 hrs (s/p grossly bloodly stool Sun pm) - was getting mom's milk, now formula again this am.\n\nNutrition labs fine this am - didn't have BUN/Cr - will see if lab can add these since he is on Promod.\n\nImp/ approaching term corrected, with age-appropriate immaturity of feeding abilities. ? cow milk protein allergy - no further bloody stool past 24+ hrs; remains on PE for now given nutritional needs of prematurity.\n\nPlan/ continue to monitor cvr status, growth & development. Monitor GI status closely, consider elemental formula if bloody stool recurs & mom's milk supply not sufficient for his volume needs.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-29 00:00:00.000", "description": "Report", "row_id": 1916403, "text": "NPN 0700-\n\n\n4. TF 150/k/d BM28PM/PE28PM. Abd benign, voiding. Heme\nnegative stools x2. Infant able to bottle whole feed this\nafternoon with some encouragement. Tolerating feeds without\naspirates/emesis. Cont to work up on PO feeds and monitor\ntolerance of feeds.\n\n5. Mother in to visit this am. Mother updated on plan of\ncare. Mother d/c'd home from hospital today. Cont to\nsupport and update .\n\n6. Temp stable swaddled in OC, cobedding with sibling.\nWakes at times for feeds, alert, resting well inbetween\ncares. MAE. AFSF. Cont to promote G&D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-07 00:00:00.000", "description": "Report", "row_id": 1916444, "text": "Discharge note 0700-1630\n\nInfant dc'd to home with with twin brother. Vs stable. Hr 140-170's. resp rate 40-60's. No spells. Lung sounds clear and equal. Positive pps murmur. Color pale to . Well perfused. Temps stable. and active. Slightly drowsy followin circ. Circumcision done today at 11am. Local anesthetic given. tollerated procedure well. Small amount of bleeding. Resolved. Teaching done regarding circ care. Demonstrated ability to care for circs. Aware of s/s of infection.\n updated on discharge teaching. Please see discharge instruction sheet, bands checked with . Synagis given upon d/c. consent given. No swelling at injection site. aware to monitor site while at home for swelling. also aware if infant does not void 10 hour after circ then they must call. Np aware that infant yet to void. referal faxed to vna. calls made to confirm\ndischarge with VNA and early intervention. verbalized readiness for discharge. Car seat safety done yesturday with .\n for the twins to go home.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-30 00:00:00.000", "description": "Report", "row_id": 1916404, "text": "NPN 1900-0700\n\n\n#4FEN. O:Wt. 1875, up 35gms. Pt. on TF of 150cc/k/d of\nBM28/PE28 with promod, being given via gavage over 1 hour.\nNo spits, minimal aspirates. Abd. soft, active bowel sounds,\nno loops. Pt. offered bottle x 1 tonight, took 37cc po, good\ncoordination, tired toward end of po feed. Pt. voiding in\ngood amounts, had guaic - stool x1. A: Gaining wt., learning\nto po feed. P: Encourage po feed at least 1/shift.\n\n#5 Parenting. O: No contact with so far tonight.\n\n#6G/D. O: Temp. stable swaddled and cobedding with twin. Pt\nwaking for some cares, alert and active with cares, MAE,\nAFF.Takes pacifier. A: AGA. P: Support developmental needs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-30 00:00:00.000", "description": "Report", "row_id": 1916405, "text": "Neonatology Attending\n\"\" is 16do, 36 wks corrected. Remains in RA, open crib cobedding with brother. a/b. soft intermittent murmur.\n\nWt 1875 up 35g on TF150 MM/PE28 with Promod pg/po - took a full bottle this am. Voiding, stooling (stools heme neg >24hrs).\n\nNutrition labs with BUN 28/Cr 0.4\n\nMeds Fe\n\nImp/ approaching term corrected, age-appropriate feeding immaturity.\nHighish BUN on Promod. H/o bloody stool ? cow milk protein allergy - monitoring.\n\nPlan/ continue to monitor cvr status, growth & development. Recheck BUN tomorrow, consider d/c Promod.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-02 00:00:00.000", "description": "Report", "row_id": 1916418, "text": "Npn 1900-0700\n\n\n\n4: FEN\n\nCurrent weight 1925gms up 25gms. Total fluids remain at\n150cc/kilo/day of Bm/Pe 28. Promod being held for high bun\non . Plan to recheck on . Continues to\nalternate po/pg feeds. Bottled 45 cc at 2100. Infant has had\nno spits and min aspirates. Voiding and stooling. Had one\nseedy stool hem negative. Abd is soft with no loops. Girths\nstable. Cotninues on iron. Plan to continue to encourage po\nfeeds.\n\n5: Parenting\n\nMom in for visit. Visit not during care times. Spoke to mom\nregarding importance of comming in during care times so that\nshe and her husband can participate in care. Mom stating\nthat they will be in tomorrow at noon time. Continue to\ninvolve in care. need encouragements to\nparticipate in cares.\n\n6: G/D\n\ntemps stable in an open crib. Co-bedded with brother. \nand active with cares. Sleeps well inbetween care. Sucks\nvigourously on pacifier. Brings hands to face. AGA.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-02 00:00:00.000", "description": "Report", "row_id": 1916419, "text": "Newborn Med Attending\n\nDOL#19. No spells. AF flat, clear BS, no murmur, abd soft, MAE. Wt= up 25, on 150 cc/kg/d BM28.\nA/P: Growing premie working up on PO feeds. Monitor spells.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-02 00:00:00.000", "description": "Report", "row_id": 1916420, "text": "NPN 0700-1900\n\n\n#4 O: TF= 150cc/kg/d. Infant taking 48cc's of BM28/PE28 q 4h\nvia alternating po/pg feeds. Bottled 50cc's at 0900 this\nam. Abdomen benign; voiding and stooling yellow, seedy,\nguaic neg stools. AG stable. Minimal aspirates, no spits. A:\nTolerating feeds. P: Recheck BUN tomorrow am. Cont to\nmonitor.\n\n#5 O: No contact as yet this shift. A: Involved. P: Cont to\nsupport and update.\n\n#6 O: Infant maintaining temp in oac; cobedding with twin.\nAwake and with cares; sucks on pacifier when offered.\nSwaddled in blanket; brings hands to face for comfort. A:\nAGA. P: Cont to support development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-02 00:00:00.000", "description": "Report", "row_id": 1916421, "text": "Addendum to above NPN note:\nSee parenting note on twin #1. in briefly to visit.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-03 00:00:00.000", "description": "Report", "row_id": 1916422, "text": "Nursing Progress Note 1900-0700\n\n\nF/E/N:Infant cont's on TF 150 cc's/kg/day.Rec.BM28 49cc's\nalt. po/pg q 4 hrs.Infant bottled 50cc's with a yellow\nnipple.Weight=1.950 kg up 25 grams.Abd. soft,pos bs,no loops\nor spits minimal aspirates.Girth=24.Infant voiding and\nstooling noted trace pos. stool. aware.Abd. benighn.BUN\nlevel checked=18(25).A:Stable P:Cont.to assess tolerance and\nmontor weight gain.\n\n\nParenting:No contact from thus far.A/P:Cont. to\nupdate,support and educate.\n\n\nDEV:AFSF.Infant appears active and with cares.Sleeping\nwell b/t cares.Temp. cont's stable in open crib.Presently\nco-bedding with sibling.Infant bringing hands to face and\nmouth,intermitently sucking on pacifier.A:AGA P:Cont. to\nsupport growth and dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-03 00:00:00.000", "description": "Report", "row_id": 1916423, "text": "NICU Attending Note\n\nDOL # 20 learning to PO feed, no new concerns.\n\nFull to follow\n\nCVR/RESP: Intermittent murmur not audible this am, mild subcostal retractions, BS clear/=, in RA. Will continue to monitor.\n\nFEN: Abd benign, weight toay , up 25 gm, on TF of 150 cc/kg/d MM/PE 28, PO/PG. BUN down to 18 off of Promod. Stools slightly guiac positive, overall improved. Will continue curent management, encourage PO intake.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-06 00:00:00.000", "description": "Report", "row_id": 1916437, "text": "Neonatology Attending\nExam:\n\nComfortable in open crib. AFSF. Lungs CTA, =. CV RRR, + sys murmur LSB clearly radiating to axilla and back. 2+FP. Well perfused. Abd soft, +BS. GU nl. Ext .\n" }, { "category": "Nursing/other", "chartdate": "2193-11-06 00:00:00.000", "description": "Report", "row_id": 1916438, "text": "Clinical Nutrition:\nO:\n37 wks CGA, BB now on DoL #23\nWt: 2005g (no change o/n)-(<10th%ile); gained an average of 9 g/kg/day (19 g/day) over the last week.\nLN: 43cm (43)-(<10th%ile)\nHC: 32.5cm (32)-(25-50th%ile)\nLabs: noted\nMeds: Iron (~4.8 mg/kg/day from feeds & supplement)\nNutrition: Neosure26 @ 150 cc/kg/day (min)\n3 day average intake: ~156 cc/kg= ~135 Kcals/kg & ~3.3 g/kg of protein\nGI: x2 small spits noted yesterday\n\nA/goals:\n is getting ready for d/c home. Tolerating feeds w/ occasional small spits. Voiding & stooling. Taking above minimum, although wt was unchanged o/n. Changed to Neosure for optimal nutrition post d/c, as is still below the 10th%ile. Plan is to send home on 28Kcals if wt gain is sub-optimal tonight. Nutrition labs noted, wnl. Iron adjusted today. No changes to nutrition plan today, all set for d/c with above plan.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-06 00:00:00.000", "description": "Report", "row_id": 1916439, "text": "Npn 0700-1900\n\n\n\n4: FEN\n\nContinues on total fluids of 150cc/kilo/day of Neosure 26\ncal. Tolerating feeds well. Infant taking all po feeds. No\nngt. Infant meeting min requirments of 50cc q 4hrs. Abd exam\nbenign. Infant abd is soft and round with no loops. Voiding\nqs, no stool thus far this shift. Continues on iron. Plan to\ncontinue with all po feeds. Possible increase to 28 calories\nprior to discharge.\n\n5: Parenting\n\nNo contact thus far. Plan to continue with discharge\nteaching. Possible discharge tomorrow.\n\n6: DEV\n\nTemps stable in an open crib, cobedded with twin brother.\nInfant and active with cares. Sleeps well inbetween\ncares. Wakes for feeds. Occationally wakes inbetween cares\nfor short periods of time. Sucks vigorously on pacifier.\nBrings hands to mouth. AGA.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-14 00:00:00.000", "description": "Report", "row_id": 1916333, "text": "Admission Note\n33-6/7 week GA twin #2 admitted for prematurity\n\nMaternal Hx - 30 year old G3P1->3 woman with the following prenatal screens: blood group B positive, antiody negative, RPR non-reactive, rubella immune, GBS unknown.\n\nPregnancy Hx - for EGA 33-6/7 weeks. Spontaneous twin gestation. Antepartum course unremarkable by report. Spontaneous onset preterm labor. ROM 7 hours prior to delivery, yielding clear amniotic fluid. Intrapartum antibiotic therapy administered 5 hours prior to delivery. Progressed to spontaneous vaginal delivery under epidural anesthesia.\n\nNeonatal course - Emerged slightly hypotonic with decreased respiratory effort. Bulb suctioned, dried, brief free flow oxygen. APgars 8 at one minute, 8 at five minutes.\n\nPE\ninfant with examination consistent with 34 weeks gestation\nBW 1725g (25-50th %ile) OFC 31cm (25-50th %ile) LN 43cm (25th %ile)\nhr 186 rr 88 T 36.8 BP 68/24 (36) SaO2 98% in 0.21 FiO2\nHEENT AFSF; non-dysmorphic; palate intact; mild nasal flaring; neck/mouth normal\nCHEST no retractions; good bs bilat; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent; 3-vessel umbilical cord\nCNS active, alert, tone AGA; suck/root/gag/grasp/Moro normal\nINTEG normal\nMSK normal spine/limbs/hips/clavicles\n\nImpression\n33-6/7 week GA male twin #2 with\n1. Sepsis risk, based on preterm labor with unknown maternal GBS colonization status, partially attenutated through intraprtum antibiotic therapy > 4 hours prior to delivery\n2. Transitional respirations, resolving\n\nPlan\nInfant has been admitted to NICu for monitoring and management of prematurity. We will maintain oxygen saturations 94-98%.\n\nCardiac examination is unremarkable. Maintain mean BP > 38 mmHg. MOnitor for signs of PDA.\n\nFeeds will be withheld until cardiorespiratory stability is established, with IV maintenacne in the interim. A CBC and blood cutlure have been drawn and broad spectrum antibiotic therapy started for anticipated course of 48 hours pending CBC and culture results and clinical symptoms.\n\nParents updated by NNP Rivers.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-16 00:00:00.000", "description": "Report", "row_id": 1916343, "text": "Social Work\n\nMet with parents today, mother to be discharged home, teary that she is leaving babies. Parents bonding well, getting more involved in cares. Couple have an older daughet at home.\nSpke to father, mother quiet, sad holding infant. Dad with questions re benfits for mother or infants. Parents have insurance through father's work at hospital, mother works in dietry at . Have suggested that father call his benefits office to determine if mother would qualify for any disability insurance due to the fact that babies were born several weeks early.\nWill plan to follow up with parents early next week.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-06 00:00:00.000", "description": "Report", "row_id": 1916440, "text": "Npn 0700-1900\n:\n\n in for visit. Discharge teaching done with family.\nPlease see addendum to twin #1's note.\n" }, { "category": "Nursing/other", "chartdate": "2193-11-07 00:00:00.000", "description": "Report", "row_id": 1916441, "text": "NPN\n\n\n#4\nInfant remains on min 150cc/k of Neosure26 q4 hours. Infant\nbottled well and has taken 60-70cc. Abd is soft; voiding;\nno stool noted. Wt is up 50gms-2055. Infant took in\n179cc/k yesterday.\n\n#5\nNo contact thus far from the .\n\n#6\nInfant remains in an open crib co-bedding with her sister.\nInfant is with cares; waking prior to feedings and\neager to eat. Sleeps well between cares.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-11-07 00:00:00.000", "description": "Report", "row_id": 1916442, "text": "Neonatology Attending Note\nDay 24\n\nRA. RR40-50s. Cl and =. No A&Bs. +PPS murmur. HR 150-170s. Wt 2055, up 50. Min 150 NeoSure26. Nl voiding and stooling. In open crib.\n\nPlan:\n - Doing great. Will proceed with discharge as planned.\n - Please refer to bedside chart and dictated discharge summary for further detail\n - Will receive synagis as Father is a smoker\n - Call pedi\n\nt>30m\n" }, { "category": "Nursing/other", "chartdate": "2193-11-07 00:00:00.000", "description": "Report", "row_id": 1916443, "text": "4 FEN\n5 Parenting\n6 Alt in Growth and Development\n\nREVISIONS TO PATHWAY:\n\n 4 FEN; resolved\n 5 Parenting; resolved\n 6 Alt in Growth and Development; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-16 00:00:00.000", "description": "Report", "row_id": 1916344, "text": "NPN days\n\n\nRESP: Infant continues on room air. Resp rates 36-68,\nO2sats 98-100%. No desats, no bradys, no apnea noted.\nlungs clear and equal. No grunting or flaring, mild\nsubcostal retractions noted occas. Continue to monitor\nclosely.\n\nCV: No murmur noted. Heart rates 124-150's. BP today 59/30\nmean 43. Infant is . Will continue to monitor closely.\n\nID: Blood cultures negative. Antibiotics DC'd , no s/s of\ninfection. Will continue to monitor for s/s of infection.\nProblem resolved.\n\nFEN: Total fluid increased today to 100cc/k/d. Enteral\nfeeds increased today 20cc/k/d . Up to 50cc/k/d at noon\nof PE20. IVF 50cc/k/d of D10 with 2MEq nacl and 1MEq kcl.\nBaby is voiding urine output this shift 3.1cc/hour. No\nstool. Abdomen is soft and benign, no loops, no spits, asp\n0-0.2cc., abd girth 21.5-22cm. Will continue to advance\nfeedings. Monitor closely for s/s of feeding intolerance.\n\nParenting: Parents in today prior to mothers discharge from\npostpartum floor. Family meeting held, parent packet given.\nSeen by social worker . Mother held infant\nfor short period of time today. Parents plan to return\ntonight for 8p cares. Will continue to support and update.\n\nAlt in G/D: Infant in servo isolette, nested with\nsheepskin. Alert and awake for cares, sleeping well between\ncares. Uses pacifier occas. with feeds. Will continue with\ndevelopmental cares\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-19 00:00:00.000", "description": "Report", "row_id": 1916356, "text": "Neonatology Attending Note\nDay 5\n\nRA. Sats 98-100%. RR 30-50s. Cl and =. No A&Bs. Mild sc rtxns. HR 130-160s. No murmur. BP 63/35, 47. , sl jaundice.\n\nBili 7.3/0.4.\n\nWt 1660, up 20 gms. TF 140 cc/k/day. PE20. PO/PG. Tolerating well. Max asp 3.2. Nl voiding and stooling (g-). In air isolette.\n\nPlan:\n1. CVR monitoring\n2. Increase to 150 cc/k/day\n3. Probable increase in cals tomorrow\n4. Follow jaundice clinically\n" }, { "category": "Nursing/other", "chartdate": "2193-10-19 00:00:00.000", "description": "Report", "row_id": 1916357, "text": "NPN 0700-1900\n\n\nRESP: In room air with sats 97-100%. breath sounds are\nclear and equal. Occasional, mild subcostal retractions.\nRR 30-40's. No apnea or bradycardia.\nA/P: Stable- cont to follow closely.\n\nF&N: Tf increased to 150cc/kg/d of BM/PE20. Infant was\nbottled at 0800- took 15cc with some chin support. NG feeds\ndelivered over 40minutes and infant has had 2 small spits\nthis shift. Abd is softly rounded with active bowel sounds\nand no loops. Ag20.5cm-21cm. Max aspirate-.6cc. Voiding\nwell. Stooled x2, heme negative.\nA/P: Monitor tolerance to feeds- ? lengthen feeding time.\nPlan is to increase cals tomorrow.\n\n: Mom and Dad and sister were in to visit at 1300.\nupdated at the bedside and plan made to do baths tomorrow.\ndid not hold , but held for ~30 minutes.\n\nG&D: Temp is stable in air-controlled isolette. Infant has\na shirt on and is swaddled. He is alert and active with\ncares. eagerly takes his pacifier.\nA/P: AGA\n\nBILI: Am bili- 7.3/.4/6.9- Infant is slightly jaundiced-\nwill follow clinically.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-19 00:00:00.000", "description": "Report", "row_id": 1916358, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, , RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-15 00:00:00.000", "description": "Report", "row_id": 1916338, "text": "NPN days\n\n\nRESP: Baby is in room air with O2sats between 99-100%, RR\n36-86 (mostly between 40-60) lungs are clear and equal, no\nGrunting or flaring. Occasional mild subcostal retractions.\n Continue to monitor resp. status closely.\n\nCV: No murmur noted. HR's 120-160, baby is , 55/38\nwith mean43 and 67/31 with mean 46. HCT 47.3. Continue to\nmonitor closely.\n\nID: Continues on ampi and gent for R/O sepsis, BC pending.\nCBC benign. No signs of infection noted. Will continue\nwith antibiotics, check gent level after 3rd dose. Check\nBlood culture tommorow.\n\nFEN: TF 80cc/k/d. Started on enteral feedings at 30cc/k/d,\nPE20 9cc per feeding, attempted to bottle feed infant, NG\ntube placed d/t poor effort, gavage fed the rest of feeds.\nLytes today 138/4.8/103/25 and Bili 4.6, 0.3. IVF 50cc/k/d\nof D10 with 2MEq of nacl and 1MEq of Kcl, running at\n3.6cc/hour. abdomen soft, asp. 0.4cc, abdominal girths\n22-22.5cm. DS today 73-97. Urine output over last 12hours\n3.6cc/k/hour. Will continue per feeding plan.\n\nParenting: Parents up breifly today to visit infants.\nUpdated on infants status. Mother is still very tired.\nWill continue to update and support.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-15 00:00:00.000", "description": "Report", "row_id": 1916339, "text": "Neonatology-NNP Physical Exam\n\nInfant remains on CPAP 6 RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with fair air entry, tachypniec. No murmur, RRR, pulses +2, . Abdomen soft, non-distended with active bowel sounds, no HSM. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-15 00:00:00.000", "description": "Report", "row_id": 1916340, "text": "NPN days addendum\n\n\nAlt in G/D: Infant moved to servo isolette today, nested\nwith sheepskin. Awake and alert with cares, sleeping well\nbetween cares, using pacifier for comfort occasionally.\ncontinue with developmental cares.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-16 00:00:00.000", "description": "Report", "row_id": 1916341, "text": "npn 1900-0700\n\n\n\n1: resp\n\nresp rate 40-60's. sats 95% and greater. Lung sounds clear\nand equal. Mild subcostal retractions with no increased wob.\nNo spells and no dsats. No grunting or nasal flarring noted.\n\n2: CV\n\nNo murur. Hr 140-160's. and well perfused. pulses wnl.\nBP 53/32 mean of 45.\n\n3: ID\n\ncontinues on amp and gent for 48 hr rule out. No s/s of\ninfection noted. will continue to monitor for symptoms of\ninfection.\n\n4: FEN\n\nCurrent weight 1690 gms. total fluids remain at\n80cc/kilo/day . ivf are at 50cc/kilo/day of d10 with 2 na\nand 1 meq of kcl. Feeds are at 30cc/kilo/day of Pe 20.\nTolerating feeds well. No aspirates and no spits. abd is\nsoft with no loops. Voiding q diaper change. No stool thus\nfar. girths stable. dstick 79.\n\n\n\n5: Parenting:\n\nNo contact thus far this shift.\n\n6: G/D\n\ntemps stable in a servo isolette. alert and active with\ncares. sleeps well inbetween. sucks vigourously on pacifier.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-16 00:00:00.000", "description": "Report", "row_id": 1916342, "text": "Neonatology Attending Note\nDay 2\n\nx 33 6/7w\n\nRA. Sats 99-100%. Occas mild rtxns. No A&Bs. No murmur. HR 140-160s. BP 59/30, 43. .\n\nTF 80 cc/k/day. Wt 1690, down 35 gms. PE20 at 30 cc/k/day + 50 cc/k/day D10 . Tolerating enteral feedings. d/s 79. u/o 3.9. No stool. Abd exam remains benign.\n\nOn amp/gent.\n\n138/4.8/103/25\nBili 4.6/0.3\n\nIn isolette.\n\nPlan:\n1. Monitor for AOP. Continued CVR monitoring.\n2. Inc TF to 100cc/k/day. Con't feeding advance.\n3. d/c abx if cx remain negative at 48 hours.\n4. Follow bili levels. No photo yet.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-20 00:00:00.000", "description": "Report", "row_id": 1916359, "text": "NPN 1900-0700\n\n\n1. O: Ls clear. O2 sats 99-100% RA. RR 30-50's. No spells.\nA/P: Cont to monitor resp status.\n\n4. O: Wt 1670 gms, up10. Tf 150cc/kg of BM/PE20 via ngt.\nVoiding and stooling G-. Min asp. no spits. Ag20-21cm. A/P:\nCont to monitor wt, abd, and tol of feeds. Cont to encourage\npo.\n\n5. No ontact from family thus far this shift.\n\n6. O: Temp stable swaddled in air isolette. Alert and\nactive with cares. A/P: Cont to monitor temp. Cont to\ncluster care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-20 00:00:00.000", "description": "Report", "row_id": 1916360, "text": "Neonatology\nRA. No spells. Comfortable appearing. No murmur.\n\nWt 1670 up 10. Tolerating feeds at 150 cc/k/d. Abdomen benign.\nTo adavnce to 22 cal and monitor tolerance.\n\nTemp stable.\n\nBili in 8 range yesterday.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-18 00:00:00.000", "description": "Report", "row_id": 1916350, "text": "NPN 1900-0700\nNPN 1900-0700 Continued\n\n4. O: Wt. -35g 1640g TF=120cc/kg/d. IV fluid infusing via order @ 10cc/kg/d. Infant receiving 110cc/kg/d of PE 20 32cc every 4 hours via gavage. Min. Aspirates noted. Abdomen soft. +b.s. Bottled 6cc x1. Vdg q.s. No stool noted as yet. A: Tolerating feeds P; Continue to feed as tolerated.\n\n5. O: No parental contact noted thus far. P; Continue to update,educate & support.\n\n6. O: maintaining temperature in heated isolette. Swaddled with boundaries. Sucks on pacifier at times. Bright-eyed. Alert with cares. MAE. A: AGA P; Continue to support development.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-18 00:00:00.000", "description": "Report", "row_id": 1916351, "text": "Neonatology Attending\n\nDay 4\n\nRemains in RA. No bradycardia, murmur. TF at 120 cc/kg/d. Advancing to full feeds of PE 20. Minimal aspirates. Blood glucose 83. Passed two stools. Active and alert. Bilirubin 8.6/0.4. Stable temperature in air-controlled incubator.\n\nDoing well overall. Adequate breathing control maturity evident so far. Tolerating feeds well. Will encourage po feeds and continue advance of enteral volume. Weaning from incubator. Family up to date.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-18 00:00:00.000", "description": "Report", "row_id": 1916352, "text": "Clinical Nutrition:\nO:\nFormer 33 weeker, BB now on DoL #4\nMaternal history/delivery reviewed.\nWt @ birth: 1725g (10-25th%ile)\nCurrent wt: 1640g (-35g o/n); down ~5% from birth wt.\nBirth LN: 43cm (~25th%ile )\nBirth HC: 31cm (25-50th%ile)\nLabs: noted\nDsticks: 83,85 over previous 24hrs\nTF: will advance to 140 cc/kg later today\nNutrition: PE20 @ 110 cc/kg/day; advancing by 20 cc/kg \nGI: x2 stools this am\n\nA/goals:\nTolerating initial advancement of feeds, will reach full volume this evening & IVF will be d/c. Initial Lytes & dsticks are stable. Voiding & stooling (first stools noted today). Once @ full feeds for ~12-24hrs can begin to advance Kcals per NICU protocol. Growth goals: ~15 g/kg/day, 0.5-1.0 cm/wk for HC & ~1.0 cm/wk for LN. Start Iron once @ 24Kcals. Check nutrition labs once @ goal feeds for ~1week. Will cont. to follow progress w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-18 00:00:00.000", "description": "Report", "row_id": 1916353, "text": "1. in RA, RR 30-50's, BBS clear, equal, mild sc\nrets, sats 98-100 A: stable respiratory P: cont to monitor.\n4. TF increased to 140cc/k/d, feedings of PE 20 37cc q4h pg\nover 40 min. abd soft, no loops, voiding and passing neg\nstool, minimal aspirates, iv to hep lock A: tolerating\nfeedings P: advance by 10/k at 12am, cont to monitor/assess.\n5. no contact so far this shift.\n6. temps stable swaddled in air heat isolette, active and\nalert with cares P: continue to support growth and\ndevelopment.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-18 00:00:00.000", "description": "Report", "row_id": 1916354, "text": "NNP Physical Exam\n\nPE: , jaundiced, AFOF, breath sounds clear/equal with comfortable WOB, no murmur, abd sfot, non distended, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-19 00:00:00.000", "description": "Report", "row_id": 1916355, "text": "NPN 1900-0700\n\n\n1. O: Ls clear. RR 30-50's. O2 sats>96% RA. Mild subcostal\nretractions. No spells. A: No A&B's. P: Cont to monitor resp\nstatus.\n\n4. O: Wt 1660 gms, up 20. TF 140cc/kg at 2400 of PE20 via\nngt. 1 spit. Max asp approx. 3cc. Voiding and stooling G-.\nAg 21-22cm. A: Tol feeds. P: Cont to monitor wt, abd, and\ntol of feeds.\n\n5. O: No contact with thus far this shift.\n\n6. O: Temp stable swaddled in covered air isolette. Alert\nand active with cares. Sucking on pacifier. A/P: Cont to\ncluster care. Cont to monitor temp.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-22 00:00:00.000", "description": "Report", "row_id": 1916367, "text": "Npn 1900-0700\n\n\n\n1: resp\n\ncontinues on ra. sats 955 and greater. resp rate 40-60's.\nlungs are clear and equal. No retractions and no increased\nwob. no spells and no dsats. Will continue to monitor for\nchanges in resp status.\n\n4: FEN\n\nCurrent weight 1695 up 20gms. Total fluids are at\n150cc/kilo/day of Pe /BM 224. Tolerating gavage feeds.\nAttempted to po feed at 0800. Infant po'd 5 cc. infant\nuncoordinated with feeds and tired easily. infant abd is\nsoft with no loops. voiding and stooling. infant has had no\nspits and no aspirates. girths stable. started on iron.\n\n5: Parenting\n\nNo contact thus far with .\n\n6: G/d\n\ntemps stable in an air heated isolettte. alert and active\nwith cares. sleeps well inbetween cares. fontanells soft and\nflat\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-22 00:00:00.000", "description": "Report", "row_id": 1916368, "text": "Neonatology Attending\n\nDay 7\n\nRemains in RA. RR 30-60s. No murmur. HR 120-150s. No bradycardia. WEight 1695 gms (+20). TF at 150 cc/kg/d. On PE/BM 24. Gavaged with occasional po attempts. Passing stool. Stable temperature on servo-control.\n\nADequate breathing control most recently. Will continue to monitor closely. ADvancing to 26 cals/oz feeds today. Encouraging po feeds.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-22 00:00:00.000", "description": "Report", "row_id": 1916369, "text": "Neonatology-NNP Progress Note\nPE: Remains in his isolette, in room air, bbs cl=, rrr s1s2 no murmur, (reportedly intermittent) abd soft, nontender, afso, active with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2193-10-22 00:00:00.000", "description": "Report", "row_id": 1916370, "text": "NPN 0700-1900\n\n1 Respiratory Distress\n\n#4 FEN\nO: TF=150cc/kg/day of PE/BM26, 44cc q4hr. Infant took 17cc\nat 8am. 1 Small spit. Minimal aspirates. AG=23cm. V/S, heme\nneg. Abdominal exam benign. Active bowel sounds. A:\nTolerating feeds. P: Continue to monitor and encourage PO\nfeeds.\n\n#5 Parenting\nO: No contact w/ thus far A: Unable to assess at\nthis time.\n\n#6 G&D\nO: Infant remains in air isolette, swaddled. Temp stable.\nA/A w/ cares. Sleeps well in between cares. A: AGA P:\nContinue to monitor and support G&D.\n\nREVISIONS TO PATHWAY:\n\n 1 Respiratory Distress; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-22 00:00:00.000", "description": "Report", "row_id": 1916371, "text": "0700- NPN\n\nI agree with above note by , Co-Worker. Please see\nflowsheet for details of assessment.\n\nADDENDUM TO FEN: Infant's feedings are given pg over 50min. He is offered po feedings x1 qshift.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-23 00:00:00.000", "description": "Report", "row_id": 1916372, "text": "4: FEN Current weight 1700 gms. Total fluids remain at\n150cc/kilo/day. Tolerating feeds well. Voiding and stooling.\nInfant had one med spit. min asirates. Infant bottled 10cc's\nat midnight. Infant uncoordinated and tired easily. Will\ncontinue to encourage po feeds. Abd exam benign. Abd soft\nwith no loops. Continues on iron.\n\n\n\n\n5: Parenting\n\nNo contact thus far this shift.\n\n6: G/D\n\nTemps stable in an air heated isolette. Alert and active\nwith cares. Sleeps well inbetween cares. Sucks vigourously\non pacifier and brings hands to face.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-23 00:00:00.000", "description": "Report", "row_id": 1916373, "text": "Neonatology Attending\n is 9do, 35+ wks corrected. Remains in RA, isolette; no a/b, sats >94%.\n\nWt 1700g up 5 (not yet back to Bwt) on TF150 MM/PE26 pg>po; voiding, stooling.\n\nMeds Fe\n\nImp/ Age-appropriate feeding & thermoregulatory immaturity. Tolerating 26cal/oz feeds past 24hrs. Bwt at 10th %ile.\n\nPlan/ continue to monitor cvr status, growth & development. will add Promod to feeds today & anticipate nutrition labs on Monday.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-24 00:00:00.000", "description": "Report", "row_id": 1916381, "text": "Progress Note 0700-1500\n\n\n4. FEN: O: TF 150cc/kg/d of PE/BM28+PM po/pg. Bottling only\n10cc when offerred. Otherwise gavaging 44cc over 40 minutes.\nAbd exam benign, +BS, no loops. A/G . Voiding\nand stooling (heme-). No spits, min asps. Gaining wgt. A:\nTolerating feeds. P: Cont to monitor.\n\n5. : O: Mom and Dad in to visit for 1200 care.\nUpdated by RN @ bedside. Appropriate. Mom bottled and held\ninfant. Family meeting scheduled for tomorrow. A: Attentive,\nloving family. P: Cont to support and educate family.\n\n6. DEV: O: is alert/active with cares. Sleeps well\nb/w feeds. Residing in air controlled iso-> weaning temp.\nRooting and bringing hands to face. A: AGA. P: Cont to\nsupport dev needs.\n\n7. CV: O: Soft int murmur auscultated x2. HR 140-160's.\nPulses =. Infant is and well perfused. A:\nNon-comprimising murmur. P: Cont to monitor CV status.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-24 00:00:00.000", "description": "Report", "row_id": 1916382, "text": "0700- NPN\nI agree with above note by , Co-Worker.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-25 00:00:00.000", "description": "Report", "row_id": 1916383, "text": "NPN\n\n\n#4 F/N O=Abd soft,+bs, no loops. Tolerating feeds of Pe 28\ncals w/Promod w/o spits. Minimal asps. AG stable. Wt down 10\ngms.Bottled slowly 10cc out of 44cc x1.Ng feeds given on a\npump over 40 mins.A= Tolerating feeds well.P= Monitor wt\ngain+ feeding tolerance.\n#5 - No contact yet tonight.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-25 00:00:00.000", "description": "Report", "row_id": 1916384, "text": "Neonatology Attending\n\"\" is 11do, 35 wks corrected. Remains in RA, low/weaning isolette. No a/b. H/o intermittent soft murmur; cv status stable.\n\nWt 1725 down 10 on TF150 PE28 with Promod pg>>po; some spits (none since gavage duration increased this am). Voiding, stooling.\n\nMeds Fe\n\nImp/ age-appropriate feeding & thermoregulatory immaturity. Just increased to 28cal/oz feeds yesterday.\n\nPlan/ continue to monitor cvr status, growth & development - consider adjusting nutritional intake if spits &/or wt loss continue.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-25 00:00:00.000", "description": "Report", "row_id": 1916385, "text": "NPN: See flowsheet for obj data not mentioned\n\n7 Alt in CV\n\n4. FEN: Feedings ordered to continue at PE28 with promod at\n150c/k/d = 44cc feeds q 4 hours. Had one spit before 0900\nfeed. Gave feeds over 1 hour and no spits rest of day.\nGavaged first two feeds and bottled for 10 cc at last feed\nwith a large amount of encouragement. Girth stable, voiding,\nstools x 2 that were guiac negative. Plan: Continue current\nfeeding plan.\n\n5. Parenting: Mother notified at noon that team would not be\nable to have scheduled family meeting due to MD \nto attend. Mother called at 1700 stating she would not be\nhere for 1700 feeding but plans to bring breastmeilk in this\nevening. Plan: Continue support of bonding relationship and\nassist parental education.\n\n6. DEV: Temp stable in air controlled isolette when swaddled\nwith cap. Slowly weaning the air temp. Brings hands to face\nto comfort self. Sleepy with cares except at 1700. Plan:\ncontinue to provide developmentally appropriate cares.\n\nREVISIONS TO PATHWAY:\n\n 7 Alt in CV; d/c'd\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2151-01-13 00:00:00.000", "description": "Report", "row_id": 1336501, "text": "See ICU admit history for PMH.\n\n77 year old male admitted from the ED from Rehab found obtunded\nbradycardia,hypotensive with resp depression. Given atropine by EMS with an increase in HR. Upon arrival to the pt received narcan IV\nwith increase in GCS and agitation requiring 4 point restraints in the ED. Pt is on MSContin for back pain related to osteomyletis that he is currently being treated for.\nIn the , pt had a PEA arrest requiring 1 minute of CPR/atropine and epi with return of perfusing rhythmn and BP. Levophed initiated to keep MAP>65. See flowsheet for current dosing.\nArrived to MICU intubated with (1)U PRBC's hanging. See flowsheet for current vent setiings/ABG's. Minimal secretions when suctioned. No gag No cough.\nPupils are fixed and dilated. Draws both lower extremities up to chest with bilateral + babsinski. Does not follow commands. ? if pt had a\nseizure when eyes were deviated to the left with face/tongue twitching. MD aware. Versed with resolution of symptoms. Head CT done stat. No bleed. Old right infarct.\nSR with PAC's/PVC's and when pt is hypotensive QRS appears to widened.\n12 lead EKG done.\nEcho done at bedside. US/EEG pending to be done.\nSee flowsheet for labs/current objective data.\nHypothermic upon arrival to unit. BAIR HUGGER placed. Rectal temps remain low at this time.\nMD to place OGT tube.\n(2) U FFP infusing for possible abd tap for INR 1.7. + bright red blood from mouth. MD aware.\nFamily in and updated on POC.\n\nPlan: Maintain and support hemodynamics,OGT by MD,US,EEG,levophed titration as needed,monitor labbs including lactic acid and HCT.\n" }, { "category": "Nursing/other", "chartdate": "2151-01-13 00:00:00.000", "description": "Report", "row_id": 1336502, "text": "ADdendum:\n\nEndoscopy at bedside. See full report in chart. + hemorragic blebs(?).\nHypotensive despite FFP,levo and IVF boluses. Vasopressin added to therapy.\nLeft SC TLC placed. Awaiting read.\nBleeding from mout,rectum,+hematuria. HCT sent. results pending.\n" }, { "category": "Nursing/other", "chartdate": "2151-01-13 00:00:00.000", "description": "Report", "row_id": 1336503, "text": "pt received from ED today after coding in the ED. Slow eann from 100% FiO2 has been possible . He was taken to CT for image of head. Pt continues to bleed from mouth through shift.\n" }, { "category": "Echo", "chartdate": "2151-01-13 00:00:00.000", "description": "Report", "row_id": 102374, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypostension. PEA Arrest.\nHeight: (in) 65\nWeight (lb): 123\nBSA (m2): 1.61 m2\nBP (mm Hg): 80/55\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 16:07\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous hypertrophy of\nthe interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%). TVI E/e' < 8, suggesting normal PCWP (<12mmHg).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Mildly dilated aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Normal PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality.\n\nConclusions:\n1.The left atrium is normal in size.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). Tissue velocity imaging demonstrates an E/e' <8 suggesting a\nnormal left ventricular filling pressure.\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic root is mildly dilated.\n5.The aortic valve leaflets are mildly thickened. No aortic regurgitation\nseen.\n6.The mitral valve leaflets are mildly thickened. No mitral regurgitation is\nseen.\n7.The estimated pulmonary artery systolic pressure is normal.\n8.There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of .,\nno mitral regurgitation is seen which may be due to the suboptimal images on\nthe present study.\n\n\n" }, { "category": "ECG", "chartdate": "2151-01-13 00:00:00.000", "description": "Report", "row_id": 295061, "text": "Baseline artifac. Atrial fibrillation with a rapid ventricular response.\nGeneralized low QRS voltage. Right bundle-branch block. Diffuse ST-T wave\nabnormalities with what appears to be a prolonged QTc interval, although this\nis difficult to measure. Consider metabolic/electrolyte/drug effect. Clinical\ncorrelation is suggested. Since the previous tracing earlier this date atrial\nfibrillation is now present.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2151-01-13 00:00:00.000", "description": "Report", "row_id": 295062, "text": "Probable sinus rhythm with atrial premature beats but baseline artifact makes\nassessment difficult. Left atrial abnormality. Low QRS voltage. Right\nbundle-branch block. Diffuse ST-T wave abnormalities with prolonged\nQTc interval. Cannot exclude metabolic/electrolyte/drug effect. Clinical\ncorrelation is suggested. Since the previous tracing oearlier this date\ntachycardia is now absent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2151-01-13 00:00:00.000", "description": "Report", "row_id": 295063, "text": "Baseline artifact. Irregulasr tachycardia of uncertain mechanism. It may be\natrial fibrillation but baseline artifact makes assessment difficult. Low limb\nlead voltage. Right bundle-branch block. Diffuse non-specific ST-T wave\nabnormalities with what appears to be prolonged QTc interval, although this is\ndifficult to measure. Clinical correlation is suggested. Since the previous\ntracing earlier this date irregular tachycardia is now present and further\nST-T wave changes are seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2151-01-13 00:00:00.000", "description": "Report", "row_id": 295064, "text": "Baseline artifact. Sinus rhythm. Left atrial abnormality. Generalized low\nvoltage. Right bundle-branch block. Modest diffuse low amplitude T wave changes\nwith what appears to be a prolonged QTc interval, although this is difficult to\nmeasure. Clinical correlation is suggested. Since the previous tracing\nof QRS voltage is lower, low amplitude T wave changes are present and\nthe QTc interval appears prolonged.\nTRACING #1\n\n" } ]

[ { "category": "ECG", "chartdate": "2122-05-06 00:00:00.000", "description": "Report", "row_id": 243445, "text": "Normal sinus rhythm, rate 92. Delayed precordial R wave progression.\nPossible anteroseptal myocardial infarction of indeterminate age.\nPossible inferior myocardial infarction of indeterminate age. Borderline\nlow voltage in the precordial leads. Generalized non-specific repolarization\nabnormalities. Compared to the previous tracing of supraventricular\ntachy-arrhythmia at a rate of 169 has given way to normal sinus rhythm.\n\n" }, { "category": "ECG", "chartdate": "2122-05-01 00:00:00.000", "description": "Report", "row_id": 243446, "text": "Supraventricular tachycardia most likely representing atrio-ventricular\nnodal re-entrant tachycardia or orthodromic atrio-ventricular reciprocating\ntachycardia. Compared to the previous tracing supraventricular tachycardia\nis now present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2122-05-01 00:00:00.000", "description": "Report", "row_id": 243447, "text": "Ectopic atrial tachycardia. Compared to the previous tracing of \nan ectopic atrial rhythm is now evident.\nTRACING #1\n\n" }, { "category": "Physician ", "chartdate": "2122-05-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 579728, "text": "Chief Complaint: Respiratory distress\n HPI:\n 84 year old female s/p partial hip replacement presenting from \n after aspiration event. Over the last week, the patient was treated\n with IVF for hypernatremia and also 3 days of levofloxacin for a fever\n of 101.5 and WBC of 19K. Evaluation included a UCx with no growth and a\n CXR which demonstrated mild CHF. Per report, the patient improved\n with these interventions until today when she was eating lunch and had\n vomited.\n .\n In the , O2 recorded as 73% and she was placed on a NRB with\n improvement to 81%.\n .\n In the ED, vitals were: 100.5 120 124/78 42 82% NRB. CXR demonstrated\n LLL infiltrate. She was given vancomycin, zosyn and acetaminophen and\n admitted.\n .\n On arrival to the MICU, patient appeared ill, and quickly went into a\n tachyarrhythmia.\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 08:15 PM\n Other medications:\n Levaquin 500 mg 1 tab(s) Q24H\n Tramadol 50 mg tab TID\n Hydromorphone 2 mg tab(s) Q6H prn\n Citalopram 40 mg 1 tab(s) once a day\n Rrazodone 50 mg 1 tab qhs\n Os-cal 500 mg-200 IU one \n Prilosec OTC 20 mg 1 tab(s) once a day\n Acetaminophen 500 mg 2 tab(s) Q4H prn\n Colace sodium 100 mg 1 cap(s) \n Senna 8.6 mg 1 tab once a day (at bedtime)\n Pregabalin 150 mg 1 cap(s) \n Lidocaine topical 5% 1 app TID\n Cranberry extract 250mg one tid\n Tramadol 50 mg tab TID\n Simvastatin 10 mg 1 tab(s) once a day (at bedtime)\n Folic acid 1 mg 1 tab(s) once a day\n MVI 1 tab qd\n Docusate sodium 100 mg 1 cap(s) \n Past medical history:\n Family history:\n Social History:\n Vulvodynia\n Depression\n Dementia\n Amyloid Angiopathy\n Constipation\n Gout\n Liver cysts\n Spinal stenosis\n Urinary retention: with Foley, has not yet returned for urodynamics\n S/P right hip hemiarthroplasty with Dr. in \n .\n Grandmother with dementia. Sister with dementia.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She is originally from and been living here since\n .\n She was an executive administrator for a computer company. She has been\n at BH for 1 year since . Before that she was living in her at\n home then was admitted for inability for self care.\n .\n Review of systems:\n Flowsheet Data as of 09:05 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.1\nC (98.7\n HR: 96 (72 - 172) bpm\n BP: 128/60(74) {93/43(54) - 128/75(87)} mmHg\n RR: 25 (18 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,425 mL\n 1,220 mL\n PO:\n TF:\n IVF:\n 1,425 mL\n 970 mL\n Blood products:\n Total out:\n 260 mL\n 275 mL\n Urine:\n 260 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,165 mL\n 945 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 94%\n ABG: 7.39/39/73./23/0\n PaO2 / FiO2: 77\n Physical Examination\n Tm 103 in ED. RR 30, 88% on 15L NRB. HR 110. Elderly, ill-appearing\n female lying in bed with NRB, responding to verbal stimuli with head\n nods. MM dry. JVP 8cm. Anicteric. Lungs with rales at both bases,\n worse on left side, and ronchi scattered throughout. Air movement was\n decent. Heart tachy, regular. Abdomen was firm without guarding or\n rebound tenderness. Extremities cool with no clubbing, cyanosis, or\n edema. Skin with mult. echymoses, no rashes or lesions.\n .\n Labs / Radiology\n 108 K/uL\n 10.2 g/dL\n 128 mg/dL\n 0.7 mg/dL\n 28 mg/dL\n 23 mEq/L\n 126 mEq/L\n 3.6 mEq/L\n 155 mEq/L\n 31.1 %\n 8.9 K/uL\n [image002.jpg]\n \n 2:33 A6/12/ 10:20 PM\n \n 10:20 P6/12/ 11:47 PM\n \n 1:20 P6/13/ 05:04 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.0\n 8.9\n Hct\n 31.1\n 31.1\n Plt\n 102\n 108\n Cr\n 0.7\n 0.7\n TropT\n <0.01\n TC02\n 24\n Glucose\n 700\n 128\n Other labs: PT / PTT / INR:15.4/31.8/1.4, CK / CKMB /\n Troponin-T:41//<0.01, ALT / AST:23/15, Alk Phos / T Bili:86/0.4,\n Differential-Neuts:82.0 %, Band:0.0 %, Lymph:15.5 %, Mono:1.8 %,\n Eos:0.5 %, Lactic Acid:1.7 mmol/L, Albumin:2.5 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.3 mg/dL\n Images:\n CT Head - No acute intracranial process.\n .\n CT Ab/pelvis: FOS.\n .\n CXR - New left lower lobe consolidation and small right\n infrahilar airspace opacity. Findings are concerning for multifocal\n pneumonia versus aspiration.\n .\n EKG: Sinus tachy on admission. Went into an SVT to 170s after\n transfer to MICU.\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETES MELLITUS (DM), TYPE I\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is an 84 year old female with dementia, recent falls and hip\n fracture, amyloid angiopathy, and severe pain from spinal stenosis who\n is admitted with fever, hypoxia after a witnessed aspiration event.\n She has imaging findings consistent with multifocal pneumonia. She\n also has hypernatremia.\n .\n # Pneumonia: Obtain sputum sample, and suction as possible. Use vanco /\n zosyn for coverage. DNI, and did not tolerate CPAP in ED. Check ABG,\n repeat lactate.\n .\n # Hypernatremia: Dry on exam. Will rehydrate with D51/2 NS, repeat\n lytes. Check osms.\n .\n # Tachyarrhythmia: Responded to IV lopressor.\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals\n .\n # Code: DNR/DNI - son is aware that she may not survive pneumonia, and\n did not want dramatic measures done.\n .\n # Communication:HCP: Nils : \n secondary contact grand daughter \n .\n # Disposition: ICU\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2122-05-02 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 579729, "text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 84 yo W s/p THR , witnessed aspiration at yesterday. already on\n levofloxacin for UTI. O2 sat 70s at , brought to EW started on\n vanc/zosyn/flagyl. ABG on high flow 7.39/39/73. Transient SVT,\n converted to NSR with lopressor.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: dementia\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 08:15 PM\n Other medications:\n see resident note\n Past medical history:\n Family history:\n Social History:\n see resident note\n amyloid\n R THR\n Dementia\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Living in nursing home for past year. Son lives locally.\n Review of systems:\n Flowsheet Data as of 09:18 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.1\nC (98.7\n HR: 96 (72 - 172) bpm\n BP: 128/60(74) {93/43(54) - 128/75(87)} mmHg\n RR: 25 (18 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,425 mL\n 1,217 mL\n PO:\n TF:\n IVF:\n 1,425 mL\n 967 mL\n Blood products:\n Total out:\n 260 mL\n 275 mL\n Urine:\n 260 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,165 mL\n 942 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 94%\n ABG: 7.39/39/73./23/0\n PaO2 / FiO2: 77\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 108 K/uL\n 31.1 %\n 10.2 g/dL\n 128 mg/dL\n 0.7 mg/dL\n 28 mg/dL\n 23 mEq/L\n 126 mEq/L\n 3.6 mEq/L\n 155 mEq/L\n 8.9 K/uL\n [image002.jpg]\n 10:20 PM\n 11:47 PM\n 05:04 AM\n WBC\n 9.0\n 8.9\n Hct\n 31.1\n 31.1\n Plt\n 102\n 108\n Cr\n 0.7\n 0.7\n TropT\n <0.01\n TC02\n 24\n Glucose\n 700\n 128\n Other labs: PT / PTT / INR:15.4/31.8/1.4, CK / CKMB /\n Troponin-T:41//<0.01, ALT / AST:23/15, Alk Phos / T Bili:86/0.4,\n Differential-Neuts:82.0 %, Band:0.0 %, Lymph:15.5 %, Mono:1.8 %,\n Eos:0.5 %, Lactic Acid:1.7 mmol/L, Albumin:2.5 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.3 mg/dL\n Fluid analysis / Other labs: No leukocytosis\n Imaging: LLL and RUL infiltrate as well as right paracardiac\n infiltrate, improved (though not resolved) since arrival, suggestion a\n component of pneumonitis as well as possible pneumonia.\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETES MELLITUS (DM), TYPE I\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Aspiration PNA\n Vanc/zosyn given. Change to levofloxacin.\n Hypoxemic resp failure.\n Still requiring high flow oxygen.\n Will likely improve as pneumonitis component resolves.\n Hypernatremia\n Euvolemic, most likely.\n D/C NS infusions.\n ICU Care\n Nutrition:\n Comments: NPO pending family discussion\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines / Intubation:\n 18 Gauge - 06:30 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2122-05-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 579744, "text": "Chief Complaint: Respiratory distress\n HPI:\n 84 year old female s/p partial hip replacement presenting from \n after aspiration event. Over the last week, the patient was treated\n with IVF for hypernatremia and also 3 days of levofloxacin for a fever\n of 101.5 and WBC of 19K. Evaluation included a UCx with no growth and a\n CXR which demonstrated mild CHF. Per report, the patient improved\n with these interventions until today when she was eating lunch and had\n vomited.\n .\n In the , O2 recorded as 73% and she was placed on a NRB with\n improvement to 81%.\n .\n In the ED, vitals were: 100.5 120 124/78 42 82% NRB. CXR demonstrated\n LLL infiltrate. She was given vancomycin, zosyn and acetaminophen and\n admitted.\n .\n On arrival to the MICU, patient appeared ill, and quickly went into a\n tachyarrhythmia.\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 08:15 PM\n Other medications:\n Levaquin 500 mg 1 tab(s) Q24H\n Tramadol 50 mg tab TID\n Hydromorphone 2 mg tab(s) Q6H prn\n Citalopram 40 mg 1 tab(s) once a day\n Rrazodone 50 mg 1 tab qhs\n Os-cal 500 mg-200 IU one \n Prilosec OTC 20 mg 1 tab(s) once a day\n Acetaminophen 500 mg 2 tab(s) Q4H prn\n Colace sodium 100 mg 1 cap(s) \n Senna 8.6 mg 1 tab once a day (at bedtime)\n Pregabalin 150 mg 1 cap(s) \n Lidocaine topical 5% 1 app TID\n Cranberry extract 250mg one tid\n Tramadol 50 mg tab TID\n Simvastatin 10 mg 1 tab(s) once a day (at bedtime)\n Folic acid 1 mg 1 tab(s) once a day\n MVI 1 tab qd\n Docusate sodium 100 mg 1 cap(s) \n Past medical history:\n Family history:\n Social History:\n Vulvodynia\n Depression\n Dementia\n Amyloid Angiopathy\n Constipation\n Gout\n Liver cysts\n Spinal stenosis\n Urinary retention: with Foley, has not yet returned for urodynamics\n S/P right hip hemiarthroplasty with Dr. in \n .\n Grandmother with dementia. Sister with dementia.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She is originally from and been living here since\n .\n She was an executive administrator for a computer company. She has been\n at BH for 1 year since . Before that she was living in her at\n home then was admitted for inability for self care.\n .\n Review of systems:\n Flowsheet Data as of 09:05 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.1\nC (98.7\n HR: 96 (72 - 172) bpm\n BP: 128/60(74) {93/43(54) - 128/75(87)} mmHg\n RR: 25 (18 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,425 mL\n 1,220 mL\n PO:\n TF:\n IVF:\n 1,425 mL\n 970 mL\n Blood products:\n Total out:\n 260 mL\n 275 mL\n Urine:\n 260 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,165 mL\n 945 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 94%\n ABG: 7.39/39/73./23/0\n PaO2 / FiO2: 77\n Physical Examination\n Tm 103 in ED. RR 30, 88% on 15L NRB. HR 110. Elderly, ill-appearing\n female lying in bed with NRB, responding to verbal stimuli with head\n nods. MM dry. JVP 8cm. Anicteric. Lungs with rales at both bases,\n worse on left side, and ronchi scattered throughout. Air movement was\n decent. Heart tachy, regular. Abdomen was firm without guarding or\n rebound tenderness. Extremities cool with no clubbing, cyanosis, or\n edema. Skin with mult. echymoses, no rashes or lesions.\n .\n Labs / Radiology\n 108 K/uL\n 10.2 g/dL\n 128 mg/dL\n 0.7 mg/dL\n 28 mg/dL\n 23 mEq/L\n 126 mEq/L\n 3.6 mEq/L\n 155 mEq/L\n 31.1 %\n 8.9 K/uL\n [image002.jpg]\n \n 2:33 A6/12/ 10:20 PM\n \n 10:20 P6/12/ 11:47 PM\n \n 1:20 P6/13/ 05:04 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.0\n 8.9\n Hct\n 31.1\n 31.1\n Plt\n 102\n 108\n Cr\n 0.7\n 0.7\n TropT\n <0.01\n TC02\n 24\n Glucose\n 700\n 128\n Other labs: PT / PTT / INR:15.4/31.8/1.4, CK / CKMB /\n Troponin-T:41//<0.01, ALT / AST:23/15, Alk Phos / T Bili:86/0.4,\n Differential-Neuts:82.0 %, Band:0.0 %, Lymph:15.5 %, Mono:1.8 %,\n Eos:0.5 %, Lactic Acid:1.7 mmol/L, Albumin:2.5 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.3 mg/dL\n Images:\n CT Head - No acute intracranial process.\n .\n CT Ab/pelvis: FOS.\n .\n CXR - New left lower lobe consolidation and small right\n infrahilar airspace opacity. Findings are concerning for multifocal\n pneumonia versus aspiration.\n .\n EKG: Sinus tachy on admission. Went into an SVT to 170s after\n transfer to MICU.\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETES MELLITUS (DM), TYPE I\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is an 84 year old female with dementia, recent falls and hip\n fracture, amyloid angiopathy, and severe pain from spinal stenosis who\n is admitted with fever, hypoxia after a witnessed aspiration event.\n She has imaging findings consistent with multifocal pneumonia. She\n also has hypernatremia.\n .\n # Pneumonia: Obtain sputum sample, and suction as possible. Use vanco /\n zosyn for coverage. DNI, and did not tolerate CPAP in ED. Check ABG,\n repeat lactate.\n .\n # Hypernatremia: Dry on exam. Will rehydrate with D51/2 NS, repeat\n lytes. Check osms.\n .\n # Tachyarrhythmia: Responded to IV lopressor.\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals\n .\n # Code: DNR/DNI - son is aware that she may not survive pneumonia, and\n did not want dramatic measures done.\n .\n # Communication:HCP: Nils : \n secondary contact grand daughter \n .\n # Disposition: ICU\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2122-05-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 579748, "text": "Chief Complaint: Respiratory distress\n HPI:\n 84 year old female s/p partial hip replacement presenting from \n after aspiration event. Over the last week, the patient was treated\n with IVF for hypernatremia and also 3 days of levofloxacin for a fever\n of 101.5 and WBC of 19K. Evaluation included a UCx with no growth and a\n CXR which demonstrated mild CHF. Per report, the patient improved\n with these interventions until today when she was eating lunch and had\n vomited.\n .\n In the , O2 recorded as 73% and she was placed on a NRB with\n improvement to 81%.\n .\n In the ED, vitals were: 100.5 120 124/78 42 82% NRB. CXR demonstrated\n LLL infiltrate. She was given vancomycin, zosyn and acetaminophen and\n admitted.\n .\n On arrival to the MICU, patient appeared ill, and quickly went into a\n tachyarrhythmia.\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 08:15 PM\n Other medications:\n Levaquin 500 mg 1 tab(s) Q24H\n Tramadol 50 mg tab TID\n Hydromorphone 2 mg tab(s) Q6H prn\n Citalopram 40 mg 1 tab(s) once a day\n Rrazodone 50 mg 1 tab qhs\n Os-cal 500 mg-200 IU one \n Prilosec OTC 20 mg 1 tab(s) once a day\n Acetaminophen 500 mg 2 tab(s) Q4H prn\n Colace sodium 100 mg 1 cap(s) \n Senna 8.6 mg 1 tab once a day (at bedtime)\n Pregabalin 150 mg 1 cap(s) \n Lidocaine topical 5% 1 app TID\n Cranberry extract 250mg one tid\n Tramadol 50 mg tab TID\n Simvastatin 10 mg 1 tab(s) once a day (at bedtime)\n Folic acid 1 mg 1 tab(s) once a day\n MVI 1 tab qd\n Docusate sodium 100 mg 1 cap(s) \n Past medical history:\n Family history:\n Social History:\n Vulvodynia\n Depression\n Dementia\n Amyloid Angiopathy\n Constipation\n Gout\n Liver cysts\n Spinal stenosis\n Urinary retention: with Foley, has not yet returned for urodynamics\n S/P right hip hemiarthroplasty with Dr. in \n .\n Grandmother with dementia. Sister with dementia.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She is originally from and been living here since\n .\n She was an executive administrator for a computer company. She has been\n at BH for 1 year since . Before that she was living in her at\n home then was admitted for inability for self care.\n .\n Review of systems:\n Flowsheet Data as of 09:05 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.1\nC (98.7\n HR: 96 (72 - 172) bpm\n BP: 128/60(74) {93/43(54) - 128/75(87)} mmHg\n RR: 25 (18 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,425 mL\n 1,220 mL\n PO:\n TF:\n IVF:\n 1,425 mL\n 970 mL\n Blood products:\n Total out:\n 260 mL\n 275 mL\n Urine:\n 260 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,165 mL\n 945 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 94%\n ABG: 7.39/39/73./23/0\n PaO2 / FiO2: 77\n Physical Examination\n Tm 103 in ED. RR 30, 88% on 15L NRB. HR 110. Elderly, ill-appearing\n female lying in bed with NRB, responding to verbal stimuli with head\n nods. MM dry. JVP 8cm. Anicteric. Lungs with rales at both bases,\n worse on left side, and ronchi scattered throughout. Air movement was\n decent. Heart tachy, regular. Abdomen was firm without guarding or\n rebound tenderness. Extremities cool with no clubbing, cyanosis, or\n edema. Skin with mult. echymoses, no rashes or lesions.\n .\n Labs / Radiology\n 108 K/uL\n 10.2 g/dL\n 128 mg/dL\n 0.7 mg/dL\n 28 mg/dL\n 23 mEq/L\n 126 mEq/L\n 3.6 mEq/L\n 155 mEq/L\n 31.1 %\n 8.9 K/uL\n [image002.jpg]\n \n 2:33 A6/12/ 10:20 PM\n \n 10:20 P6/12/ 11:47 PM\n \n 1:20 P6/13/ 05:04 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.0\n 8.9\n Hct\n 31.1\n 31.1\n Plt\n 102\n 108\n Cr\n 0.7\n 0.7\n TropT\n <0.01\n TC02\n 24\n Glucose\n 700\n 128\n Other labs: PT / PTT / INR:15.4/31.8/1.4, CK / CKMB /\n Troponin-T:41//<0.01, ALT / AST:23/15, Alk Phos / T Bili:86/0.4,\n Differential-Neuts:82.0 %, Band:0.0 %, Lymph:15.5 %, Mono:1.8 %,\n Eos:0.5 %, Lactic Acid:1.7 mmol/L, Albumin:2.5 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.3 mg/dL\n Images:\n CT Head - No acute intracranial process.\n .\n CT Ab/pelvis: FOS.\n .\n CXR - New left lower lobe consolidation and small right\n infrahilar airspace opacity. Findings are concerning for multifocal\n pneumonia versus aspiration.\n .\n EKG: Sinus tachy on admission. Went into an SVT to 170s after\n transfer to MICU.\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETES MELLITUS (DM), TYPE I\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is an 84 year old female with dementia, recent falls and hip\n fracture, amyloid angiopathy, and severe pain from spinal stenosis who\n is admitted with fever, hypoxia after a witnessed aspiration event.\n She has imaging findings consistent with multifocal pneumonia. She\n also has hypernatremia.\n .\n # Pneumonia: Obtain sputum sample, and suction as possible. Use vanco /\n zosyn for coverage. DNI, and did not tolerate CPAP in ED. Check ABG,\n repeat lactate.\n .\n # Hypernatremia: Dry on exam. Will rehydrate with D51/2 NS, repeat\n lytes. Check osms.\n .\n # Tachyarrhythmia: Responded to IV lopressor.\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals\n .\n # Code: DNR/DNI - son is aware that she may not survive pneumonia, and\n did not want dramatic measures done.\n .\n # Communication:HCP: Nils : \n secondary contact grand daughter \n .\n # Disposition: ICU\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n ------ Protected Section ------\n \n Updates to admission note above:\n This is an 84 year old female with dementia, recent falls and hip\n fracture, amyloid angiopathy, and severe pain from spinal stenosis who\n is admitted with fever, hypoxia after a witnessed aspiration event and\n presents with hypernatremia.\n .\n # Aspiration pneumonitis: repeat CXR this AM was markedly better with\n defined heart borders c/w aspiration pneumonitis, not pna.\n - Continue levofloxacin which was started on at her facility.\n - Tx for 7 day course to \n - Wean O2 as tolerated\n - Speech and Swallow eval\n .\n # Hypernatremia: Dry on exam and also with AMS. Per son, she normally\n feeds herself at rehab and now barely able to respond to yes/no ?s.\n - Free water boluses down OG tube.\n - check Na Q4-6 hrs.\n .\n # Tachyarrhythmia: Responded to IV lopressor and fluid boluses.\n .\n # FEN: No IVF, replete electrolytes, free water boluses down OG tube.\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals\n # Code: DNR/DNI - son is aware that she may not survive pneumonia, and\n did not want dramatic measures done.\n # Communication:HCP: Nils : \n secondary contact grand daughter \n # Disposition: may call out to floor this PM if Na corrects.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:28 ------\n" }, { "category": "Nursing", "chartdate": "2122-05-01 00:00:00.000", "description": "Generic Note", "row_id": 579620, "text": "TITLE:\n Patient in SVT at hrs- Fluid bolus 500 mls started, IV Lopressor 5\n mgs IV given.\n" }, { "category": "Nursing", "chartdate": "2122-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579633, "text": "TITLE:\n 84F transferred from NH with aspiration PNA. Recently started on ABX\n for UTI. NH noticed worsening sats over past 2-3 days. On day of\n admission O2 in 70s on RA, increased to 80s with NRB. In ED temp 102,\n tachycardic. CXR showing multifocal PNA, started on IV ABX. 2 sets BC\n sent in ED as well as UA. Abdominal CT done in ED for noticeable\n abdominal distention and abdominal tenderness. Sent to MICU for\n management of hypoxia. Pt is DNR/DNI.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on non-rebreather mask with 15 + lits O 2, LS\n rhonchorous, Patient has a weak productive cough. O 2 sats in high\n 80\n Action:\n ABG done on NRBM 7.39/39/73.Nasotracheal suctioning done by RT-\n obtained copious amts of yellow tenacious secretions. NRBM changed to\n Hi-Flow cool neb face mask on 95 %. Continued on Vanco/ Zosyn.\n Response:\n O 2 sats 94 to 96%\n Plan:\n Continue pulmonary toilet, wean O 2 as tolerated.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Axillary temp in 100\n Action:\n Continued on antibiotic. OGT inserted- confirmed with CXR- Tylenol 650\n mgs PRN dose given x 1.\n Response:\n Axillary temp 99.8\n Plan:\n Continue monitoring, continue antibiotics, follow up on cultures.\n Electrolyte & fluid disorder, other\n Assessment:\n K + 3.2 in pm labs, Glucose 700\n Action:\n Repleted K + with K\nDur 40 meq + 20 meq via OGT. Rechecked fingerstick\n 298, started on Sliding scale Humalog, fingersticks checked q 2 hrs.\n D5\n ns was infusing at 150 mls/hr , changed to NS 125 mls/hr.\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2122-05-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 579684, "text": "Demographics\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Tenacious\n Sputum source/amount: Nasotrachial Suction / Copious\n Comments: suction prn\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Plan\n Wean high flow as tolerates and nts as needed.\n" }, { "category": "Nursing", "chartdate": "2122-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579704, "text": "TITLE:\n 84F transferred from NH with aspiration PNA. Recently started on ABX\n for UTI. NH noticed worsening sats over past 2-3 days. On day of\n admission O2 in 70s on RA, increased to 80s with NRB. In ED temp 102,\n tachycardic. CXR showing multifocal PNA, started on IV ABX. 2 sets BC\n sent in ED as well as UA. Abdominal CT done in ED for noticeable\n abdominal distention and abdominal tenderness. Sent to MICU for\n management of hypoxia. Pt is DNR/DNI.\n Events :\n SVT rate of 160\ns - 170\ns, NS 500 ml given Metoprolol 5\n mgs x 2 given- RHYTHM REVERTED BACK TO SINUS , HR -70\n Nasotracheal suctioning done by RT x 3\n obtained copius\n Tenacious yellowish tan sputum- sent for culture.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on non-rebreather mask with 15 + lits O 2, LS\n rhonchorous, Patient has a weak productive cough. O 2 sats in high\n 80\n Action:\n ABG done on NRBM 7.39/39/73.Nasotracheal suctioning done by RT-\n obtained copious amts of yellow tenacious secretions. NRBM changed to\n Hi-Flow cool neb face mask on 95 %. Continued on Vanco/ Zosyn.\n Response:\n O 2 sats 94 to 96%\n Plan:\n Continue pulmonary toilet, wean O 2 as tolerated.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Axillary temp in 100\n Action:\n Continued on antibiotic. OGT inserted- confirmed with CXR- Tylenol 650\n mgs PRN dose given x 1.\n Response:\n Current Axillary temp 97.8\n Plan:\n Continue monitoring, continue antibiotics, follow up on cultures.\n Electrolyte & fluid disorder, other\n Assessment:\n K + 3.2 in pm labs, Glucose 700\n Action:\n Repleted K + with K\nDur 40 meq + 20 meq via OGT. Rechecked fingerstick\n 298, started on Sliding scale Humalog, fingersticks checked q 2 hrs.\n D5\n NS was infusing at 150 mls/hr , changed to NS 125 mls/hr\n Response:\n NA+ 155 in am labs, 0.9% NS drip changed to 0.45 % NS @ 75 mls/hr .\n Fingersticks 140\ns to 150\n Plan:\n Continue monitoring Lytes, Fingersticks Q 6 hrs., Monitor Urine\n output.\n" }, { "category": "Physician ", "chartdate": "2122-05-03 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 579911, "text": "Chief Complaint:\n 24 Hour Events:\n CALLED OUT\n \n - Finding on presented CXR largely resolved by AM suggesting aspiration\n pneumonitis, so she was changed back to her initial Abx course of\n Levofloxacin for 7 days to end on .\n - Sodium remained elevated so free-water flushes were increased down OG\n tube.\n - Per son, pt could answer a few questions and feed herself at her\n nursing home and now is off her baseline - ? related to hypernatremia.\n - She should get Speech and swallow eval when mental status improves.\n - Patient had several very large BMs which may account for K+ wasting.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium - 05:01 PM\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.9\nC (98.4\n HR: 100 (93 - 115) bpm\n BP: 143/72(89) {109/53(67) - 156/98(107)} mmHg\n RR: 23 (14 - 36) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 3,473 mL\n 1,285 mL\n PO:\n TF:\n IVF:\n 1,753 mL\n 585 mL\n Blood products:\n Total out:\n 865 mL\n 620 mL\n Urine:\n 865 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,608 mL\n 665 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n GEN: Miniamlly responsive to questions, but awake and comfortable\n HEENT: OG tube in place\n PULM: Crackles bilaterally\n CV: RRR, No M/R/G\n ABD: soft NT/ND\n Extr: Pulses 2+, 1+ edema at ankles.\n Labs / Radiology\n 114 K/uL\n 9.9 g/dL\n 194 mg/dL\n 0.5 mg/dL\n 21 mEq/L\n 3.2 mEq/L\n 18 mg/dL\n 121 mEq/L\n 148 mEq/L\n 30.2 %\n 8.7 K/uL\n [image002.jpg]\n 10:20 PM\n 11:47 PM\n 05:04 AM\n 12:03 PM\n 04:54 AM\n WBC\n 9.0\n 8.9\n 8.7\n Hct\n 31.1\n 31.1\n 30.2\n Plt\n 102\n 108\n 114\n Cr\n 0.7\n 0.7\n 0.6\n 0.5\n TropT\n <0.01\n TCO2\n 24\n Glucose\n 94\n Other labs: PT / PTT / INR:15.7/38.2/1.4, CK / CKMB /\n Troponin-T:41//<0.01, ALT / AST:23/15, Alk Phos / T Bili:86/0.4,\n Differential-Neuts:82.0 %, Band:0.0 %, Lymph:15.5 %, Mono:1.8 %,\n Eos:0.5 %, Lactic Acid:1.7 mmol/L, Albumin:2.5 g/dL, Ca++:8.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:1.7 mg/dL\n SPUTUM CX: GRAM STAIN (Final ):\n >25 PMNs and >10 epithelial cells/100X field.\n Gram stain indicates extensive contamination with upper respiratory\n secretions. Bacterial culture results are invalid.\n Urine Legionella : NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN\n Blood and Urine Cx: NGTD\n Assessment and Plan\n 84 year old female with dementia, recent falls and hip fracture,\n amyloid angiopathy, and severe pain from spinal stenosis who is\n admitted with fever, hypoxia after a witnessed aspiration event and\n presents with hypernatremia.\n .\n # Aspiration pneumonitis: repeat CXR was markedly better with defined\n heart borders c/w aspiration pneumonitis, not pna. Sputum cx invalid\n due to contamination. Other cx neg thus far\n - f/u cx\n - Continue levofloxacin which was started on at her facility.\n - Tx for 7 day course to \n - Wean O2 as tolerated\n - OG tube in place for PO meds\n - Continue aggressive pulmonary toilet\n - Speech and Swallow eval\n .\n # Hypernatremia: Dry on exam and also with AMS. Per son, she normally\n feeds herself at rehab and now barely able to respond to yes/no ?s. Na\n improved today.\n - Free water boluses down OG tube.\n - check Na Q6 hrs.\n .\n # Tachyarrhythmia: Initally presented with SVT that responded to IV\n lopressor and fluid boluses.\n .\n # FEN: No IVF, replete electrolytes, free water boluses down OG tube.\n # Prophylaxis: Subcutaneous heparin, famotidine\n # Access: peripherals\n # Code: DNR/DNI - son is aware that she may not survive pneumonia, and\n did not want dramatic measures done.\n # Communication:HCP: Nils : \n secondary contact grand daughter \n # Disposition: may call out to floor this PM as she is DNR/DNI.\n ICU Care\n Nutrition: NPO pending speech and swallow eval\n Glycemic Control: None\n Lines:\n 18 Gauge - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 Blocker\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Call out to floor\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above.\n Team spoke with pt's son, who clarified that her baseline mental status\n is able to answer simple questions and feeds herself.\n Aspiration PNA, on levofloxacin.\n 100.1, 140/80 100 98% on high flow 60% mask.\n I/O: 3.5/.9 plus multiple large BMs.\n exam: not answering questions. appears comfortable. moves all ext. OGT\n in place. crackles at bilateral lower lung fields, poor\n inspiration, very weak cough.\n wbc 9 hct 30 plt 114 Na 148 K 3.2 and repleted Cr 0.5\n * Hypoxemic resp failure. Aspiration pna. O2 requirement\n improving. Levofloxacin until for aspiration pna.\n * Hypernatremia improved.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:14 ------\n" }, { "category": "Nursing", "chartdate": "2122-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 579912, "text": "This is an 84 year old female with dementia, recent falls and hip\n fracture, amyloid angiopathy, and severe pain from spinal stenosis who\n is admitted with fever, hypoxia after a witnessed aspiration event.\n Dispo: DNR/DNI\n Allergies: NKDA\n Access: 1 18g piv\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CXR showing bilateral infiltrate- likely aspiration pneumonitis. Rec\n pt on high flow neb 60%. Lungs clear ronchorous bilaterally. RR\n 20-30\ns. RR 20s-30s. Weak congested cough.\n Action:\n Strict NPO with OGT in place. Aspiration precautions. NT suctioned x 1\n for scant amounts of white thick secretions. CPT performed with turns.\n Remains on PO levofloxacin for asp. Pna coverage. Weaned O2 to 40%\n high flow neb.\n Response:\n 02 requirements decreased once suctioned/CPT. Sating 97% on high flow\n neb.\n Plan:\n Wean 02 as tolerated, NT suction as needed\n Electrolyte & fluid disorder, other\n Assessment:\n NA 148, K 3.2, Rec\nd on D 5\n NS (for 1L)\n infusion completed this\n shift. Pt repleted o/n with 40 mEq PO potassium for K 3.2, vomited ~\n 100cc bilious this AM right after PO KCL dose.\n Action:\n Rec\ning 350 cc free water boluses q 4 hours- held AM free H2O \n n/v. Rec\nd 4mg ivp zofran with good effect. 40 mEq iv potassium\n currently infusing.\n Response:\n NA down to 148 on AM labs. K remains low, 40 mEq potassium currently\n infusing for K 3.2.\n Plan:\n Serial lytes, replete as needed\n Diabetes Mellitus (DM), Type I\n Assessment:\n FSBS 243 this AM. Remain NPO for strict asp. Precautions. OGT in\n place.\n Action:\n BS 234 covered with 4 units humalog.\n Response:\n Pnding.\n Plan:\n Cont. FSBS, ISS for coverage.\n ** Pt stooling large amounts of green/black liquid stool this AM.\n GUIAIC +. Flexiseal in place. Hct stable, 30. HD stable.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n 67 Inch\n Admission weight:\n 73.8 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: volvodynia, depression, dementia, amyloid\n angiopathy, constipation, gout, liver cysts, spinal stenosis\n Surgery / Procedure and date: s/p hemiarthroplasty right hip\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:138\n D:78\n Temperature:\n 99\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 27 insp/min\n Heart Rate:\n 105 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n High flow neb\n O2 saturation:\n 97% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,721 mL\n 24h total out:\n 1,200 mL\n Pertinent Lab Results:\n Sodium:\n 148 mEq/L\n 04:54 AM\n Potassium:\n 3.2 mEq/L\n 04:54 AM\n Chloride:\n 121 mEq/L\n 04:54 AM\n CO2:\n 21 mEq/L\n 04:54 AM\n BUN:\n 18 mg/dL\n 04:54 AM\n Creatinine:\n 0.5 mg/dL\n 04:54 AM\n Glucose:\n 194 mg/dL\n 04:54 AM\n Hematocrit:\n 30.2 %\n 04:54 AM\n Finger Stick Glucose:\n 234\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7\n Transferred to: 2209\n Date & time of Transfer: 1100\n" }, { "category": "Physician ", "chartdate": "2122-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 579887, "text": "Chief Complaint:\n 24 Hour Events:\n CALLED OUT\n \n - Finding on presented CXR largely resolved by AM suggesting aspiration\n pneumonitis, so she was changed back to her initial Abx course of\n Levofloxacin for 7 days to end on .\n - Sodium remained elevated so free-water flushes were increased down OG\n tube.\n - Per son, pt could answer a few questions and feed herself at her\n nursing home and now is off her baseline - ? related to hypernatremia.\n - She should get Speech and swallow eval when mental status improves.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium - 05:01 PM\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.9\nC (98.4\n HR: 100 (93 - 115) bpm\n BP: 143/72(89) {109/53(67) - 156/98(107)} mmHg\n RR: 23 (14 - 36) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 3,473 mL\n 1,285 mL\n PO:\n TF:\n IVF:\n 1,753 mL\n 585 mL\n Blood products:\n Total out:\n 865 mL\n 620 mL\n Urine:\n 865 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,608 mL\n 665 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 114 K/uL\n 9.9 g/dL\n 194 mg/dL\n 0.5 mg/dL\n 21 mEq/L\n 3.2 mEq/L\n 18 mg/dL\n 121 mEq/L\n 148 mEq/L\n 30.2 %\n 8.7 K/uL\n [image002.jpg]\n 10:20 PM\n 11:47 PM\n 05:04 AM\n 12:03 PM\n 04:54 AM\n WBC\n 9.0\n 8.9\n 8.7\n Hct\n 31.1\n 31.1\n 30.2\n Plt\n 102\n 108\n 114\n Cr\n 0.7\n 0.7\n 0.6\n 0.5\n TropT\n <0.01\n TCO2\n 24\n Glucose\n 94\n Other labs: PT / PTT / INR:15.7/38.2/1.4, CK / CKMB /\n Troponin-T:41//<0.01, ALT / AST:23/15, Alk Phos / T Bili:86/0.4,\n Differential-Neuts:82.0 %, Band:0.0 %, Lymph:15.5 %, Mono:1.8 %,\n Eos:0.5 %, Lactic Acid:1.7 mmol/L, Albumin:2.5 g/dL, Ca++:8.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETES MELLITUS (DM), TYPE I\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 Blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Call out to floor\n" }, { "category": "Physician ", "chartdate": "2122-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 579888, "text": "Chief Complaint:\n 24 Hour Events:\n CALLED OUT\n \n - Finding on presented CXR largely resolved by AM suggesting aspiration\n pneumonitis, so she was changed back to her initial Abx course of\n Levofloxacin for 7 days to end on .\n - Sodium remained elevated so free-water flushes were increased down OG\n tube.\n - Per son, pt could answer a few questions and feed herself at her\n nursing home and now is off her baseline - ? related to hypernatremia.\n - She should get Speech and swallow eval when mental status improves.\n - Patient had several very large BMs which may account for K+ wasting.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium - 05:01 PM\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.9\nC (98.4\n HR: 100 (93 - 115) bpm\n BP: 143/72(89) {109/53(67) - 156/98(107)} mmHg\n RR: 23 (14 - 36) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 3,473 mL\n 1,285 mL\n PO:\n TF:\n IVF:\n 1,753 mL\n 585 mL\n Blood products:\n Total out:\n 865 mL\n 620 mL\n Urine:\n 865 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,608 mL\n 665 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n GEN: Miniamlly responsive to questions, but awake and comfortable\n HEENT: OG tube in place\n PULM: Crackles bilaterally\n CV: RRR, No M/R/G\n ABD: soft NT/ND\n Extr: Pulses 2+, 1+ edema at ankles.\n Labs / Radiology\n 114 K/uL\n 9.9 g/dL\n 194 mg/dL\n 0.5 mg/dL\n 21 mEq/L\n 3.2 mEq/L\n 18 mg/dL\n 121 mEq/L\n 148 mEq/L\n 30.2 %\n 8.7 K/uL\n [image002.jpg]\n 10:20 PM\n 11:47 PM\n 05:04 AM\n 12:03 PM\n 04:54 AM\n WBC\n 9.0\n 8.9\n 8.7\n Hct\n 31.1\n 31.1\n 30.2\n Plt\n 102\n 108\n 114\n Cr\n 0.7\n 0.7\n 0.6\n 0.5\n TropT\n <0.01\n TCO2\n 24\n Glucose\n 94\n Other labs: PT / PTT / INR:15.7/38.2/1.4, CK / CKMB /\n Troponin-T:41//<0.01, ALT / AST:23/15, Alk Phos / T Bili:86/0.4,\n Differential-Neuts:82.0 %, Band:0.0 %, Lymph:15.5 %, Mono:1.8 %,\n Eos:0.5 %, Lactic Acid:1.7 mmol/L, Albumin:2.5 g/dL, Ca++:8.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:1.7 mg/dL\n SPUTUM CX: GRAM STAIN (Final ):\n >25 PMNs and >10 epithelial cells/100X field.\n Gram stain indicates extensive contamination with upper respiratory\n secretions. Bacterial culture results are invalid.\n Urine Legionella : NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN\n Blood and Urine Cx: NGTD\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETES MELLITUS (DM), TYPE I\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 84 year old female with dementia, recent falls and hip fracture,\n amyloid angiopathy, and severe pain from spinal stenosis who is\n admitted with fever, hypoxia after a witnessed aspiration event and\n presents with hypernatremia.\n .\n # Aspiration pneumonitis: repeat CXR was markedly better with defined\n heart borders c/w aspiration pneumonitis, not pna. Sputum cx invalid\n due to contamination. Other cx neg thus far\n - f/u cx\n - Continue levofloxacin which was started on at her facility.\n - Tx for 7 day course to \n - Wean O2 as tolerated\n - OG tube in place for PO meds\n - Speech and Swallow eval\n .\n # Hypernatremia: Dry on exam and also with AMS. Per son, she normally\n feeds herself at rehab and now barely able to respond to yes/no ?s. Na\n improved today.\n - Free water boluses down OG tube.\n - check Na Q6 hrs.\n .\n # Tachyarrhythmia: Initally presented with SVT that responded to IV\n lopressor and fluid boluses.\n .\n # FEN: No IVF, replete electrolytes, free water boluses down OG tube.\n # Prophylaxis: Subcutaneous heparin, famotidine\n # Access: peripherals\n # Code: DNR/DNI - son is aware that she may not survive pneumonia, and\n did not want dramatic measures done.\n # Communication:HCP: Nils : \n secondary contact grand daughter \n # Disposition: may call out to floor this PM as she is DNR/DNI.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 Blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Call out to floor\n" }, { "category": "Physician ", "chartdate": "2122-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 579898, "text": "Chief Complaint:\n 24 Hour Events:\n CALLED OUT\n \n - Finding on presented CXR largely resolved by AM suggesting aspiration\n pneumonitis, so she was changed back to her initial Abx course of\n Levofloxacin for 7 days to end on .\n - Sodium remained elevated so free-water flushes were increased down OG\n tube.\n - Per son, pt could answer a few questions and feed herself at her\n nursing home and now is off her baseline - ? related to hypernatremia.\n - She should get Speech and swallow eval when mental status improves.\n - Patient had several very large BMs which may account for K+ wasting.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium - 05:01 PM\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.9\nC (98.4\n HR: 100 (93 - 115) bpm\n BP: 143/72(89) {109/53(67) - 156/98(107)} mmHg\n RR: 23 (14 - 36) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Total In:\n 3,473 mL\n 1,285 mL\n PO:\n TF:\n IVF:\n 1,753 mL\n 585 mL\n Blood products:\n Total out:\n 865 mL\n 620 mL\n Urine:\n 865 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,608 mL\n 665 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n GEN: Miniamlly responsive to questions, but awake and comfortable\n HEENT: OG tube in place\n PULM: Crackles bilaterally\n CV: RRR, No M/R/G\n ABD: soft NT/ND\n Extr: Pulses 2+, 1+ edema at ankles.\n Labs / Radiology\n 114 K/uL\n 9.9 g/dL\n 194 mg/dL\n 0.5 mg/dL\n 21 mEq/L\n 3.2 mEq/L\n 18 mg/dL\n 121 mEq/L\n 148 mEq/L\n 30.2 %\n 8.7 K/uL\n [image002.jpg]\n 10:20 PM\n 11:47 PM\n 05:04 AM\n 12:03 PM\n 04:54 AM\n WBC\n 9.0\n 8.9\n 8.7\n Hct\n 31.1\n 31.1\n 30.2\n Plt\n 102\n 108\n 114\n Cr\n 0.7\n 0.7\n 0.6\n 0.5\n TropT\n <0.01\n TCO2\n 24\n Glucose\n 94\n Other labs: PT / PTT / INR:15.7/38.2/1.4, CK / CKMB /\n Troponin-T:41//<0.01, ALT / AST:23/15, Alk Phos / T Bili:86/0.4,\n Differential-Neuts:82.0 %, Band:0.0 %, Lymph:15.5 %, Mono:1.8 %,\n Eos:0.5 %, Lactic Acid:1.7 mmol/L, Albumin:2.5 g/dL, Ca++:8.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:1.7 mg/dL\n SPUTUM CX: GRAM STAIN (Final ):\n >25 PMNs and >10 epithelial cells/100X field.\n Gram stain indicates extensive contamination with upper respiratory\n secretions. Bacterial culture results are invalid.\n Urine Legionella : NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN\n Blood and Urine Cx: NGTD\n Assessment and Plan\n 84 year old female with dementia, recent falls and hip fracture,\n amyloid angiopathy, and severe pain from spinal stenosis who is\n admitted with fever, hypoxia after a witnessed aspiration event and\n presents with hypernatremia.\n .\n # Aspiration pneumonitis: repeat CXR was markedly better with defined\n heart borders c/w aspiration pneumonitis, not pna. Sputum cx invalid\n due to contamination. Other cx neg thus far\n - f/u cx\n - Continue levofloxacin which was started on at her facility.\n - Tx for 7 day course to \n - Wean O2 as tolerated\n - OG tube in place for PO meds\n - Continue aggressive pulmonary toilet\n - Speech and Swallow eval\n .\n # Hypernatremia: Dry on exam and also with AMS. Per son, she normally\n feeds herself at rehab and now barely able to respond to yes/no ?s. Na\n improved today.\n - Free water boluses down OG tube.\n - check Na Q6 hrs.\n .\n # Tachyarrhythmia: Initally presented with SVT that responded to IV\n lopressor and fluid boluses.\n .\n # FEN: No IVF, replete electrolytes, free water boluses down OG tube.\n # Prophylaxis: Subcutaneous heparin, famotidine\n # Access: peripherals\n # Code: DNR/DNI - son is aware that she may not survive pneumonia, and\n did not want dramatic measures done.\n # Communication:HCP: Nils : \n secondary contact grand daughter \n # Disposition: may call out to floor this PM as she is DNR/DNI.\n ICU Care\n Nutrition: NPO pending speech and swallow eval\n Glycemic Control: None\n Lines:\n 18 Gauge - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 Blocker\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Call out to floor\n" }, { "category": "Nursing", "chartdate": "2122-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 579906, "text": "This is an 84 year old female with dementia, recent falls and hip\n fracture, amyloid angiopathy, and severe pain from spinal stenosis who\n is admitted with fever, hypoxia after a witnessed aspiration event.\n Dispo: DNR/DNI\n Allergies: NKDA\n Access: 1 18g piv\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on high flow neb 60%. Lungs clear ronchorous bilaterally. RR\n 20-30\ns. RR 20s-30s. Weak congested cough.\n Action:\n Strict NPO with OGT in place. Aspiration precautions. NT suctioned x 1\n for scant amounts of white thick secretions. CPT performed with turns.\n Remains on PO levofloxacin for asp. Pna coverage. Weaned O2 to 40%\n high flow neb.\n Response:\n 02 requirements decreased once suctioned/CPT. Sating 97% on high flow\n neb.\n Plan:\n Wean 02 as tolerated, NT suction as needed\n Electrolyte & fluid disorder, other\n Assessment:\n NA 148, K 3.2, Rec\nd on D 5\n NS (for 1L)\n infusion completed this\n shift. Pt repleted o/n with 40 mEq PO potassium for K 3.2, vomited ~\n 100cc bilious this AM right after PO KCL dose.\n Action:\n Rec\ning 350 cc free water boluses q 4 hours- held AM free H2O \n n/v. Rec\nd 4mg ivp zofran with good effect. 40 mEq iv potassium\n currently infusing.\n Response:\n NA down to 148 on AM labs. K remains low, 40 mEq potassium currently\n infusing for K 3.2.\n Plan:\n Serial lytes, replete as needed\n Diabetes Mellitus (DM), Type I\n Assessment:\n FSBS 243 this AM. Remain NPO for strict asp. Precautions. OGT in\n place.\n Action:\n BS 234 covered with 4 units humalog.\n Response:\n Pnding.\n Plan:\n Cont. FSBS, ISS for coverage.\n" }, { "category": "Nursing", "chartdate": "2122-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 579907, "text": "This is an 84 year old female with dementia, recent falls and hip\n fracture, amyloid angiopathy, and severe pain from spinal stenosis who\n is admitted with fever, hypoxia after a witnessed aspiration event.\n Dispo: DNR/DNI\n Allergies: NKDA\n Access: 1 18g piv\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CXR showing bilateral infiltrate- likely aspiration pneumonitis. Rec\n pt on high flow neb 60%. Lungs clear ronchorous bilaterally. RR\n 20-30\ns. RR 20s-30s. Weak congested cough.\n Action:\n Strict NPO with OGT in place. Aspiration precautions. NT suctioned x 1\n for scant amounts of white thick secretions. CPT performed with turns.\n Remains on PO levofloxacin for asp. Pna coverage. Weaned O2 to 40%\n high flow neb.\n Response:\n 02 requirements decreased once suctioned/CPT. Sating 97% on high flow\n neb.\n Plan:\n Wean 02 as tolerated, NT suction as needed\n Electrolyte & fluid disorder, other\n Assessment:\n NA 148, K 3.2, Rec\nd on D 5\n NS (for 1L)\n infusion completed this\n shift. Pt repleted o/n with 40 mEq PO potassium for K 3.2, vomited ~\n 100cc bilious this AM right after PO KCL dose.\n Action:\n Rec\ning 350 cc free water boluses q 4 hours- held AM free H2O \n n/v. Rec\nd 4mg ivp zofran with good effect. 40 mEq iv potassium\n currently infusing.\n Response:\n NA down to 148 on AM labs. K remains low, 40 mEq potassium currently\n infusing for K 3.2.\n Plan:\n Serial lytes, replete as needed\n Diabetes Mellitus (DM), Type I\n Assessment:\n FSBS 243 this AM. Remain NPO for strict asp. Precautions. OGT in\n place.\n Action:\n BS 234 covered with 4 units humalog.\n Response:\n Pnding.\n Plan:\n Cont. FSBS, ISS for coverage.\n ** Pt stooling large amounts of green/black liquid stool this AM.\n GUIAIC +. Flexiseal in place. Hct stable, 30. HD stable.\n" }, { "category": "Nursing", "chartdate": "2122-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579585, "text": "84F transferred from NH with aspiration PNA. Recently started on ABX\n for UTI. NH noticed worsening sats over past 2-3 days. On day of\n admission O2 in 70s on RA, increased to 80s with NRB. In ED temp 102,\n tachycardic. CXR showing multifocal PNA, started on IV ABX. 2 sets BC\n sent in ED as well as UA. Abdominal CT done in ED for noticeable\n abdominal distention and abdominal tenderness. Sent to MICU for\n management of hypoxia. Pt is DNR/DNI.\n" }, { "category": "Respiratory ", "chartdate": "2122-05-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 579848, "text": "Demographics\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan /\n Sputum source/amount: Nasotrachial Suction / Copious\n Comments: continue to suction as needed\n" }, { "category": "Nursing", "chartdate": "2122-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579610, "text": "84F transferred from NH with aspiration PNA. Recently started on ABX\n for UTI. NH noticed worsening sats over past 2-3 days. On day of\n admission O2 in 70s on RA, increased to 80s with NRB. In ED temp 102,\n tachycardic. CXR showing multifocal PNA, started on IV ABX. 2 sets BC\n sent in ED as well as UA. Abdominal CT done in ED for noticeable\n abdominal distention and abdominal tenderness. Sent to MICU for\n management of hypoxia. Pt is DNR/DNI.\n Pt admitted to unit, arousable to voice, not following command,\n withdrawing to pain, PERRL. ST on monitor, NBP WNL, good pedal pulses.\n Arrived on NRB satting high 80s, lung sounds clear, perisistent\n non-productive cough. +BS, belly soft, nontender. Foley in place, urine\n clear yellow. Skin intact.\n" }, { "category": "Physician ", "chartdate": "2122-05-02 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 579816, "text": "Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 84 yo W s/p THR , witnessed aspiration at yesterday. already on\n levofloxacin for UTI. O2 sat 70s at , brought to EW started on\n vanc/zosyn/flagyl. ABG on high flow 7.39/39/73. Transient SVT,\n converted to NSR with lopressor.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: dementia\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 08:15 PM\n Other medications:\n see resident note\n Past medical history:\n Family history:\n Social History:\n see resident note\n amyloid\n R THR\n Dementia\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Living in nursing home for past year. Son lives locally.\n Review of systems:\n Flowsheet Data as of 09:18 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.1\nC (98.7\n HR: 96 (72 - 172) bpm\n BP: 128/60(74) {93/43(54) - 128/75(87)} mmHg\n RR: 25 (18 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,425 mL\n 1,217 mL\n PO:\n TF:\n IVF:\n 1,425 mL\n 967 mL\n Blood products:\n Total out:\n 260 mL\n 275 mL\n Urine:\n 260 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,165 mL\n 942 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 94%\n ABG: 7.39/39/73./23/0\n PaO2 / FiO2: 77\n Physical Examination\n Dementia, no response to questions though responds to voice with turn\n of head. Withdraws to noxious stimuli, does not follow commands. PERRL.\n Poor cough.Mucosa moist. Copious secretions with frequent suctioning.\n Lungs poor inspiration but CTA. RRR. Abd NABS soft NDNT. OGT in place.\n No rashes. No edema.\n Labs / Radiology\n 108 K/uL\n 31.1 %\n 10.2 g/dL\n 128 mg/dL\n 0.7 mg/dL\n 28 mg/dL\n 23 mEq/L\n 126 mEq/L\n 3.6 mEq/L\n 155 mEq/L\n 8.9 K/uL\n [image002.jpg]\n 10:20 PM\n 11:47 PM\n 05:04 AM\n WBC\n 9.0\n 8.9\n Hct\n 31.1\n 31.1\n Plt\n 102\n 108\n Cr\n 0.7\n 0.7\n TropT\n <0.01\n TC02\n 24\n Glucose\n 700\n 128\n Other labs: PT / PTT / INR:15.4/31.8/1.4, CK / CKMB /\n Troponin-T:41//<0.01, ALT / AST:23/15, Alk Phos / T Bili:86/0.4,\n Differential-Neuts:82.0 %, Band:0.0 %, Lymph:15.5 %, Mono:1.8 %,\n Eos:0.5 %, Lactic Acid:1.7 mmol/L, Albumin:2.5 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.3 mg/dL\n Fluid analysis / Other labs: No leukocytosis\n Imaging: LLL and RUL infiltrate as well as right paracardiac\n infiltrate, improved (though not resolved) since arrival, suggestion a\n component of pneumonitis as well as possible pneumonia.\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DIABETES MELLITUS (DM), TYPE I\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Aspiration PNA\n Vanc/zosyn given. Change to levofloxacin.\n Hypoxemic resp failure.\n Still requiring high flow oxygen.\n Will likely improve as pneumonitis component resolves.\n Hypernatremia\n Euvolemic, most likely.\n D/C NS infusions. Repeat.\n ICU Care\n Nutrition:\n Comments: NPO pending family discussion\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines / Intubation:\n 18 Gauge - 06:30 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2122-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579812, "text": "84yr old nursing home patient admitted with probable aspiration\n pneumonia and high 02 requirement. See admission data for pmh. She\n was admitted with code status of DNR/DNI.\n Electrolyte & fluid disorder, other\n Assessment:\n SR with occasional pac\ns with no ventricular ectopy noted. Serum K\n 2.9 and serum sodium 155\n Action:\n 60meq\ns KCL given via OGT and gastric free water boluses initiated. Dw5\n at 100cc/hr for 500cc infused.\n Response:\n Remains without ventricular ectopy. PM serum K 3.7 and serum sodium 153\n Plan:\n Follow ekg and note any new ectopy or arrhythmia. Continue free water\n q4hrs. Repeat lytes at 2100.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on high flow 02 at 93%. . Lungs coarse with rhonci and\n decreased at bases. Pt has weak, loose non productive cough. RR 16-28.\n Action:\n Nasotracheally suctioned for moderate, thick tan secretions, 02\n titrated down to 50%\n Response:\n 02 sat 95%, respiratory rate unchanged. Lungs remain course with some\n rhonci that improved after suctioning.\n Plan:\n Keep hob>30 and suction prn. Follow cxr and abg\ns as ordered and\n indicated. Encourage coughing and deep breathing. Titrate 02 as\n tolerated to keep 02 sat >92%.\n" }, { "category": "Nursing", "chartdate": "2122-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579869, "text": "This is an 84 year old female with dementia, recent falls and hip\n fracture, amyloid angiopathy, and severe pain from spinal stenosis who\n is admitted with fever, hypoxia after a witnessed aspiration event.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on high flow neb titrated between 60-95%. Lungs rhonchorous\n throughout. RR 20-30\ns. Appears tachypnic at times. Strong congested\n cough\n Action:\n Strict NPO with OGT in place. Aspiration precautions. NT suctioned x 2\n for copious amounts of thick secretions. CPT performed with turns\n Response:\n 02 requirements decreased once suctioned\n Plan:\n Wean 02 as tolerated, NT suction as needed\n Electrolyte & fluid disorder, other\n Assessment:\n NA 153, K 3.1\n Action:\n Started on D51/2 NS @ 75 for one liter in addition to 350 cc free water\n boluses A 4 hours. 60 PO K given for hypokalemia\n Response:\n NA down to 148 on AM labs. K remains low awaiting repletion orders\n Plan:\n Serial lytes, replete as needed\n" }, { "category": "Nursing", "chartdate": "2122-05-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 579868, "text": "This is an 84 year old female with dementia, recent falls and hip\n fracture, amyloid angiopathy, and severe pain from spinal stenosis who\n is admitted with fever, hypoxia after a witnessed aspiration event.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on high flow neb titrated between 60-95%. Lungs rhonchorous\n throughout. RR 20-30\ns. Appears tachypnic at times. Strong congested\n cough\n Action:\n Strict NPO with OGT in place. Aspiration precautions. NT suctioned x 2\n for copious amounts of thick secretions. CPT performed with turns\n Response:\n 02 requirements decreased once suctioned\n Plan:\n Wean 02 as tolerated, NT suction as needed\n Electrolyte & fluid disorder, other\n Assessment:\n NA 153, K 3.1\n Action:\n Started on D51/2 NS @ 75 for one liter in addition to 350 cc free water\n boluses A 4 hours. 60 PO K given for hypokalemia\n Response:\n NA down to 148 on AM labs. K remains low awaiting repletion orders\n Plan:\n Serial lytes, replete as needed\n" }, { "category": "Radiology", "chartdate": "2122-05-07 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1084376, "text": " 8:35 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for osbstructing pattern\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with dementia, vomiting, hyperactive BS, unable to relate\n discomfort.\n REASON FOR THIS EXAMINATION:\n eval for osbstructing pattern\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:50 AM\n PFI: No bowel obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old woman with dementia, vomiting, hyperactive bowel sounds,\n and unable to relate discomfort. Evaluate for obstruction pattern.\n\n COMPARISON: CT abdomen and pelvis .\n\n FINDINGS: Single supine portable radiograph was obtained of the abdomen. Air\n is seen throughout the small bowel and colon without evidence for bowel\n obstruction. Exclusion of the hemidiaphragms limits evaluation for free air,\n but within the limits of the study there is no free air. Nasogastric tube is\n present in the stomach. A right hip hemiarthroplasty is present. There are\n degenerative changes in the lumbar spine.\n\n There is a 11-mm radiodensity projecting over the area of the left kidney\n which may represent renal calculi. No hydronephrosis was noted on the CT\n examination approximately one week prior and if this is a renal calculi, is\n nonobstructing.\n\n IMPRESSION: No bowel obstruction. Nasogastric tube in the stomach. Possible\n nonobstructing 11-mm renal calculi on the left.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-05-07 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1084377, "text": ", H. MED FA2 8:35 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for osbstructing pattern\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with dementia, vomiting, hyperactive BS, unable to relate\n discomfort.\n REASON FOR THIS EXAMINATION:\n eval for osbstructing pattern\n ______________________________________________________________________________\n PFI REPORT\n PFI: No bowel obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-05-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083483, "text": " 11:11 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval for change, fluid overlaod\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with pneumonia,\n REASON FOR THIS EXAMINATION:\n Eval for change, fluid overlaod\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with pneumonia.\n\n Portable AP chest radiograph was compared to obtained at 02:37\n p.m.\n\n The NG tube tip is in the stomach. The cardiomediastinal silhouette is\n stable. There is interval increase in the left hilar opacity that might\n represent developing of infectious process in the left perihilar area as well\n as in the left infrahilar area. The other possibility would be a combination\n of infectious process with worsening pulmonary edema, giving the central\n appearance of the abnormalities. The bibasilar opacities are also present\n more laterally and might represent the areas of infection versus atelectasis.\n No appreciable pleural effusion is demonstrated, although small pleural fluid\n cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-05-01 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1083440, "text": " 3:44 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: acute adomen: please eval for free air\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with acute abd\n REASON FOR THIS EXAMINATION:\n acute adomen: please eval for free air\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa FRI 5:32 PM\n 1. No pneumoperitoneam. Significant fecal load.\n 2. Bibasilar lung consolidation. concerning for either aspiration or PNA.\n 2. Enlarged uterus, with endometrial hypodensity. F/u with ultrasound.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old woman, with acute abdomen symptom, assess for\n pneumoperitoneum.\n\n COMPARISON: None.\n\n TECHNIQUE: Helical MDCT images were acquired from the lung bases to the pubic\n symphysis after administration of IV contrast. Multiplanar reformatted images\n were obtained.\n\n FINDINGS:\n\n CT ABDOMEN WITH CONTRAST: In the visualized lung bases, there is significant\n bibasilar consolidation with air bronchogram, concerning for infectious\n process versus aspiration. The visualized heart displays significant coronary\n artery calcification. No pericardial effusion.\n\n In the abdomen, there are two subcentimter, slightly ill-defined hypodensities\n in the liver, too small to be fully evaluated in this study. There is no\n evidence of intrahepatic biliary ductal dilatation. The gallbladder is normal\n without evidence of radiopaque gallstones. The pancreas, spleen, and adrenal\n glands are within normal limits. There are several subcentimeter\n hypodensities in the renal parenchyma bilaterally, all of them too small to be\n fully evaluated, but statistically likely to be cysts. The kidneys are\n otherwise normal- appearing without hydronephrosis. There is prompt excretion\n of IV contrast into the collecting system and proximal ureters. The stomach,\n duodenum, and non- distended loops of small bowels are unremarkable. There is\n no free air or fluid in the abdomen. There is no lymphadenopathy.\n\n CT PELVIS WITH CONTRAST: The colon has normal bowel gas but moderate fecal\n load. Right femoral prosthetic hardware results in surrounding artifacts,\n limiting the evaluation of the low pelvic structure. There is an indwelling\n Foley catheter in a collapsed bladder. The uterus is seen markedly enlarged\n for her age, with the maximal transverse dimension measuring 8 x 8 cm, and a\n large endometrial irregular hypodensity, highly suspicious for a malignant\n process. Small peripheral calcification on the uterine wall, compatible with\n partially calcified fibroids. There is no free air or fluid in the pelvis.\n (Over)\n\n 3:44 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: acute adomen: please eval for free air\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is no lymphadenopathy.\n\n BONE WINDOW: No acute fracture, dislocation or immediate hardware\n complications. No lytic or blastic lesions concerning for metastasis. Moderate\n underlying multilevel degenerative disease. Moderate calcification along the\n descending aorta and its major branches. A small sebaceous cyst is seen in\n the posterior abdominal wall.\n\n IMPRESSION:\n 1. No pneumoperitoneum. Significant fecal loading.\n 2. Bibasilar lung consolidation, concerning for pneumonia or aspiration.\n 3. Abnormally enlarged uterus, with irregular endometrial hypodensity. This\n is highly suspicious for malignant process given age. Further evaluation and\n consultation recommended.\n\n Preliminary findings were posted onto the ED dashboard at the interpretation\n of the study.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2122-05-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1083441, "text": " 3:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: altered mental status\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n altered mental status\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old woman, with mental status change. Evaluate for acute\n intracranial process.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast contiguous MDCT images were acquired through the\n brain.\n\n FINDINGS: There is no acute intracranial hemorrhage, mass effect, edema, or\n large territorial infarct. The periventricular white matter hypodensity is\n seen most prominent in the left frontal periventricular region; however,\n overall unchanged consistent with chronic microvascular ischemic disease.\n There is no shift of normally midline structures. The ventricles and sulci\n are normal in size for age and unchanged. The previously noted mucosal cysts\n in the paranasal sinuses are now resolved and the mastoid air cells are clear.\n No acute fracture is noted.\n\n IMPRESSION: No acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2122-05-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083422, "text": " 2:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for consolidation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with tachypnea and hypoxia\n REASON FOR THIS EXAMINATION:\n please eval for consolidation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old female with tachypnea and hypoxia, concerning for\n pneumonia.\n\n COMPARISON: Chest radiographs of and .\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: Allowing for differences in positioning,\n the heart size is likely not changed and the aortic contour remains tortuous.\n Lung volumes are slightly decreased compared to prior studies. In addition,\n there is new airspace opacity involving the left lower lung which does not\n obscure the left heart border but does obscure the left retrocardiac\n hemidiaphragm, consistent with a left lower lobe consolidation. There also is\n a small area of airspace opacity in the infrahilar right lower lung. No\n pneumothorax or large pleural effusion is seen. Again noted are tiny\n calcified nodules and linear scarring in the right lung apex.\n\n IMPRESSION: New left lower lobe consolidation and small right infrahilar\n airspace opacity. Findings are concerning for multifocal pneumonia versus\n aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2122-05-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083785, "text": " 8:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: fluid status, ? development of infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with dementia, spinal stenosis p/w hypernatremia and resp\n distress.\n REASON FOR THIS EXAMINATION:\n fluid status, ? development of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with dementia, spinal stenosis, presenting\n with hypernatremia and respiratory distress. Evaluate for pneumonia.\n\n Single AP chest radiograph compared to shows worsening left\n basilar and right infrahilar airspace opacities worrisome for multifocal\n pneumonia or aspiration. The cardiomediastinal contour is stable. There is\n no pleural effusion or pneumothorax. Tip of NG tube is coiled in the stomach.\n\n IMPRESSION: Worsening left basilar and right infrahilar airspace opacities\n compatible with multifocal pneumonia or aspiration.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2131-11-23 00:00:00.000", "description": "Report", "row_id": 1544145, "text": "bleeding from lt. calf vein harvest site with oozy ct's,line sites on arrival wuth hypothermia & elevated act.warmed with bair hugger,protamine given with improved ct dng but continued bleeding from leg. manual pressure held by m.d. with some slowing,suture placed with resolution.propofol weaned to off with extreme hypertension(over 200!) despite rapid titration of ntg & morphine for presumed pain. opened eyes to voice but bp too unstable to allow full wake up.nipride to bedside,propofol resumed with bp control.lower filling pressures with dropping ci,hct < 25%,prbc's infusing with improving parameters. cantonese interpreter only available in person from 8:30- 6pm,otherwise available by telephone. no family contact as yet.glucoses erratic requiring d50 & gtt titration,see flow sheet.\n" }, { "category": "Nursing/other", "chartdate": "2131-11-24 00:00:00.000", "description": "Report", "row_id": 1544146, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse with rhonchi improve somewhat with suct sm th bld sput. ABGs stable on present vent settings. Cont mech vent/PSV later as tol.\n" }, { "category": "Nursing/other", "chartdate": "2131-11-24 00:00:00.000", "description": "Report", "row_id": 1544147, "text": "NEURO- CANTONESE SPEAKING ONLY. INTUBATED/SEDATED OVERNOC. MAE SPONTANEOUSLY THIS (EVEN WITH PROPOFOL ON) FACIAL GRIMACNG WITH ORAL CARE. ATTEMPTS TO OPEN EYES TO VOICE.\n\nCV- NSR->ST. RATE CONTROLLED. BP LABILE. NEO/NTG. LOW FILLING PRESSURES,C.I LOWER BY THERMODILUTION THAN FICK. 500CC NS BOLUS X1 WITH LITTLE EFFECT.T-MAX=100.9 650MG TLENOL VIA GOT. SKIN COOL/DRY.DOPPLERABLE PULSES X4.\n\nRESP- REMAINED INTUBATED ON IMV SETTING (NO CHANGES). ABG,WNL. DATS=98%. LS CLEAR UPPERS/DIM BASE WITH SOME COURSENESS. S/S DRG FROM CT.\n\nGU/GI- ABD SOFT ABSENT BS. OGT-> LCWSX WITH CLEAR DRG. DWINDLING U/O DOWNT TO 12CC/HR. NO IMPROVMENT WITH FLUID BOLUS.20MG IVP LASIX WITH GREAT DIURESES.\n\nLABS- NO REPLACEMENTS NEEDED.\n\nENDO- INSULIN GTT PER CSRU PROTOCOL. GLUCOSE LEVELS 140->85.\n\nPLAN- WEAN/WAKE EXTUBATE. MONITOR HEMODYNAMICS/RENAL STATUS/GLUCOSE CONTROL.\n" }, { "category": "Echo", "chartdate": "2131-11-23 00:00:00.000", "description": "Report", "row_id": 80921, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease. Hypertension. Mitral valve disease.\nHeight: (in) 59\nWeight (lb): 116\nBSA (m2): 1.46 m2\nBP (mm Hg): 160/72\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 11:29\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Normal descending aorta diameter.\nThere are complex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild to moderate\n(+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild to moderate [+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. Results were personally reviewed with the MD caring for the\npatient. See Conclusions for post-bypass data\n\nConclusions:\nPRE-BYPASS:\n\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The aortic valve leaflets (3) are mildly thickened. Mild to moderate (+)\naortic regurgitation is seen.\n3. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n4. Mild to moderate tricuspid regurgitation.\n5. The left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler.\n6. Right ventricular chamber size and free wall motion are normal.\n7. Complex atheroma in the descending aorta.\n\nPOST-BYPASS:\n\n1. Preserved -ventricular systolic function.\n2. No evidence of aortic dissection post de-cannulation.\n3. Rest of study is unchanged from pre-bypass.\n\n\n" }, { "category": "Echo", "chartdate": "2131-11-22 00:00:00.000", "description": "Report", "row_id": 80922, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Preoperative assessment.\nHeight: (in) 59\nWeight (lb): 116\nBSA (m2): 1.46 m2\nBP (mm Hg): 153/52\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 15:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function. Transmitral Doppler\nand TVI c/w Grade I (mild) LV diastolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate (2+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Regional\nleft ventricular wall motion is normal. Transmitral Doppler and tissue\nvelocity imaging are consistent with Grade I (mild) LV diastolic dysfunction.\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened\nbut aortic stenosis is not present. Mild to moderate (+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The\npulmonary artery systolic pressure could not be determined. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Symmetric left ventricular hypertrophy with preserved global and\nregional systolic function. Mild-moderate aortic regurgitation. Moderate\nmitral regurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2131-11-23 00:00:00.000", "description": "Report", "row_id": 200382, "text": "Sinus rhythm. Minor anterolateral ST-T wave abnormalities. Compared to the\nprevious tracing of no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2131-11-22 00:00:00.000", "description": "Report", "row_id": 200383, "text": "Sinus rhythm. Anterolateral ST-T wave changes are non-specific. No previous\ntracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2131-11-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 933833, "text": " 9:16 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusion/pneumothorax please do in th\n Admitting Diagnosis: CORONARY ARTERY DISEASE;HYPERTENSION;DIABETES\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p cabg\n REASON FOR THIS EXAMINATION:\n evaluate for effusion/pneumothorax please do in the am thank you\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG. Evaluate for effusions, pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: Right IJ introducer sheath been withdrawn. There is stable\n widening of cardiomediastinal silhouette since surgery. There is small\n left-sided pleural effusion, possibly increased in size. There is persistent\n retrocardiac density, not significantly changed. There is an amorphous\n density projecting in the left mid lung, in the prior location of the chest\n tube, and presumably related to the chest tube. Pulmonary vascularity is\n normal.\n\n IMPRESSION: Persistent left retrocardiac density, that could represent\n collapse and/or consolidation, unchanged. Possibly increased left moderate\n pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-11-23 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 933352, "text": " 1:25 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE;HYPERTENSION;DIABETES\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p CABG\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:35 P.M. ON .\n\n HISTORY: Status post CABG. Suspect pneumothorax.\n\n IMPRESSION: AP chest compared to preoperative films on :\n\n Normal postoperative appearance of the heart, lungs, pleura, and\n cardiopulmonary support devices. No pneumothorax or appreciable pleural\n effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-11-22 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 933215, "text": " 3:24 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: PREOP CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with 3 vessel CAD pre-op for CABG. Patient in cath lab\n holding area and will likely be admitted West.\n REASON FOR THIS EXAMINATION:\n eval for carotid disease\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64-year-old woman with coronary artery disease. Preoperative\n evaluation for CABG.\n\n RADIOLOGIST: The study was read by Dr. .\n\n TECHNIQUE: Evaluation of the extracranial carotid arteries was performed with\n B-mode, color and spectral Doppler ultrasound.\n\n FINDINGS: With B-mode ultrasound, a small amount of plaque was seen in the\n bilateral internal carotid arteries. On the right side, peak systolic\n velocities were 98 cm/sec for the internal carotid artery, 81 cm/sec for the\n common carotid artery and 234 cm/sec for the external carotid artery. The\n right ICA/CCA ratio was 1.20.\n\n On the left side, peak systolic velocities were 151 cm/sec for the ICA, 86\n cm/sec for the CCA and 156 cm/sec for the ECA. The left ICA/CCA ratio was\n 1.75.\n\n Both vertebral arteries presented antegrade flow.\n\n COMPARISON: None available.\n\n IMPRESSION:\n 1. Less than 40% stenosis of the right internal carotid artery.\n 2. 60%-69% stenosis of the left internal carotid artery.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-11-22 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 933255, "text": " 9:50 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE;HYPERTENSION;DIABETES\\CATH\n Admitting Diagnosis: CORONARY ARTERY DISEASE;HYPERTENSION;DIABETES\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with cad, PREOP CXR\n REASON FOR THIS EXAMINATION:\n R/O CARDIOPULMONARY PROCESS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old female with coronary artery disease with preop chest\n x-ray. Rule out cardiopulmonary process.\n\n COMPARISON: None.\n\n PA AND LATERAL CHEST RADIOGRAPHS:\n\n The heart size is normal. Mediastinal and hilar contours are unremarkable.\n There is atelectasis in the right lung base. Otherwise, there are no focal\n areas of consolidation. There are no pleural effusions. No pneumothorax. The\n surrounding soft tissues and osseous structures are unremarkable.\n\n IMPRESSION:\n\n No evidence of pneumonia or pulmonary edema\n\n" }, { "category": "Radiology", "chartdate": "2131-11-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 933512, "text": " 5:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: CORONARY ARTERY DISEASE;HYPERTENSION;DIABETES\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p CABG, now s/p chest tube removal\n\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Status post CABG, chest tube removal.\n\n One portable view. Comparison with . There is increased density in\n the retrocardiac area consistent with atelectasis or consolidation. Streaky\n density at the right base probably represents minimal subsegmental atelectasis\n as well. The patient is status post median sternotomy, as before. The\n patient been extubated and a nasogastric tube been withdrawn.\n Mediastinal drains, a Swan-Ganz catheter and a left chest tube have been\n removed.\n\n IMPRESSION: Increased retrocardiac density consistent with atelectasis or\n consolidation. Subsegmental atelectasis right base.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2131-03-11 00:00:00.000", "description": "Report", "row_id": 1544219, "text": "RN progress note\nneuro: AAO x 3; slightly anxious, cooperative. Med x 2 w/ percocet for sternal pain to encourage CDB. No focal deficits.\n\nCV: NSR, ST , no VEA; 85-105. Started on metoprolol 12.5mg po @ MN w/ block to 80's during sleep.\n\nPulm: BS static bibasilar crackles; essentially CTAb after CDB.RA sats > 95 %. CT w/ min s/s drainage; no air leak.\n\nGI: abd soft, non-tneder; nl BS. +flatus; no BM. Tol cl liqs overnoc.\n\nGU: c/o significant blader/penis discomfor t w/ F/C in; D/C'd 2100 and has since voided last amount adequate\n\nMs/derm: sternum stable; wounds C/D. Cont w/ anasarca. A-line d/c'd. Introducer in until IV k infused.\n\nEndo: BG labile, requiring insulin per RISS.\n\nLabs: H/H stable; K repleted.\n\n\nP: d/c CL; start own glucose management schedule. Cont increased activity, rehab goals. D/C CT's\n\n" }, { "category": "Nursing/other", "chartdate": "2131-03-09 00:00:00.000", "description": "Report", "row_id": 1544216, "text": "7am-7pm update\nNeuro: pt alert and orientated x3. MAE and able to follow commands.\n\nCv: pt remains NSR/ST, no ectopy noted. HR 80-90's. SBP 80-120's. MAP 50-70's. pt labile at times -> SBP dropped into the low 80's with OOB to chair -> once sitting in and feet raised SBP > 100. levo gtt weaned to off. CI > 2.0. PA line dc'd without incidence and introducer left intact. hct stable. pp by doppler. pt with 2 A wires and 2 V wires -> temp pacer on a demand at 60. V wires not capturing or sensing. JP dc'd this afternoon\n\nresp: LS clear throughout. pt on 2 l nc, o2 sat 98-100%. pt with non productive cough. using IS to 1000. pt with CT intact and draining minimal serouanginous fluid, no airleak noted.\n\ngi/gu: pt with + bs. pt had 1 episode of nausea -> vomitted ~ 50 cc's brown fluid. nausea treated with reglan. appetite improved throughout the day -> ate 100% of dinner tray. foley draining clear yellow urine. UO boarderline. pt recieved 20 mg lasix x 1 -> minimal response.\n\nendo: insulin gtt weaned to off and started on SC per protocol.\n\nactivity/comfort: OOB to chiar with 2 assist -> pt became hypotensive with activity (see above). pt percocet and torodol for pain control.\n\nplan: pulm toleit, pain control, stent in the future, montitor lytes/bs, increase diet and activity as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2131-03-10 00:00:00.000", "description": "Report", "row_id": 1544217, "text": "CSRU UPDATE\nCONTINUES IN CSRU. NO EVENTS OVN. RECEIVED PERCOCET FOR PAIN. LEVO OFF. HEMODYNAMICALLY STABLE. BP RUNNING 90'S SYS WHILE SLEEPING. LSCTA. UO MARGINAL AT 30CC/HR. DR. AWARE. CONTINUE TO MONITOR. SSRI COVERAGE. PLAN: OOB IN AM, TX TO FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2131-03-10 00:00:00.000", "description": "Report", "row_id": 1544218, "text": "7am-7pm update\nneuro: pt alert and orieanted x3. MAE and able to follow commands.\n\nCV: pt remains NSR, no ectopy noted. HR 90'a. SBP 90-140's. map 60-90's. levo gtt off all day. pp by doppler\n\nresp: LS clear with dim bases bil. pt on RA -> o2 sats 94-96%. pt using IS. non productive cough. CT draining minimal serousinginous fluid, no airleak noted.\n\ngi/gu: pt with + bs, c/o nausea this am x 1 -> treated with reglan. pt able to tolerate braekfast, lunch and dinner. pt unable to void today -> foley placed at 1700 without incidence. foley drainged 400 cc's clear yellow urine when placed. foley left intact\n\nendo: elvated bs treated with reg ss insulin per protocol\n\nactivity/comfort: OOB to chair x 2. ambulated x 1 with 2 assist. while ambulating pt c/o slight lightheadness. SBP 90-80's. percoets for pain control\n\nplan: 2 in am, montitor bs -> restated 70/30 insulin. monitor lytes/hct, pulm toleit, pain control, advance activty as tolerted\n" }, { "category": "Nursing/other", "chartdate": "2131-03-08 00:00:00.000", "description": "Report", "row_id": 1544214, "text": "ADMISSION NOTE\nPT RECIEVED FROM OR ~ 1220 PM. S/P CABG X 2. LIMA -> LAD, VG -> OM. PT RECIEVED ON PROPOFOL, MILR AND LEVO GTT'S. ASESTHESIA REPORTED THAT THEY WERE UNABLE TO GRAFT THE RIGHT SIDE OF THE HEART D/T THICKENED PERICARDIUM/PERICARDIAL ADHESIONS -> ?? APPEARED AS THOUGH THE PT HAD PERICARDITIS IN THE PAST (ALTHOUGH THE PATIENT HAS NO HISTORY OF PERCARDITIS). PT WILL NEED STENT IN THE FUTURE FOR THE LEASION THAT THEY WERE NOT ABLE TO GRAFT. POST BYPASS TEE SHOWED IMPROVED SYSTOLIC FUNCTION. EF ~ 30-35% (ON MILR GTT). MILD MR.\n\nNEURO: PT ON PROPOFOL GTT. REVERSALS GIVEN AND PROPOFOL GTT WEANED TO OFF. PT ABLE TO MAE AND FOLLOW COMMNADS. PERRL. PT -> POST EXTUABTION THE PATIENT WAS ALERT AND ORIENATED X3\n\nCV: PT REMAINS NSR, NO ECTOPY NOTED. HR 80'S. BP ININTALLY LABILE -> TREATED WITH VOLUME AND LEVO GTT TITTRATED TO KEEP MAP 60-90'S. PT ON 0.03 MCG/KG/MIN MILR GTT. CI > 2.0 SVO2 63. MILR GTT TURNED OFF PER NP. PT CURRENTLY 1 UNIT PRBC FOR HCT OF 26. PP BY DOPPLER. JP TO BULB SUCTION AND DRAINING SMALL AMOUNT OF SEROUSAINGINOUS FLUID.\n\nRESP: LS CLEAR WITH DIM BASES BIL. PT WEANED AND WITHOUT DIFFICULLTY. SEE FLOWSHEET SHEET FOR ABG'S AND VENT ADJUSTMENTS. PT AND PLACED ON 40% FACE TENT. O2 SATS 98-100%. CT DRAINING MINIMAL AMOUNT SEROUSANGINSOUS FLUID. NO AILEAK NOTED.\n\n\nGI/GU: BS ABSENT. OGT DC'D WHEN EXTUBATED. PT C/O NAUSEA -> TREATED WTIH REGLAN. FOLEY DRAINING CLEAR YELLOW URINE. UO ADEQUATE\n\nENDO: PT STARTED ON INSULIN GTT AND TITRATED PER PROTOCOL\n\nPLAN: WEAN LEVO GTT AS TOLERATED, CONTINUE INSULIN GTT, MONITOR CO/CI, PULM TOLIET, PAIN CONTROL, STNET IN THE FUTURE\n" }, { "category": "Nursing/other", "chartdate": "2131-03-09 00:00:00.000", "description": "Report", "row_id": 1544215, "text": "CSRU UPDATE:\nNeuro: Intact - no issues.\n\nPulm: CS clr - good sats on 3 l NP.\n\nCV: See flowsheet. Labile BP requiring Levo. Min CT drainage, sml dumps when turned and w/ dry heaves. Periph pulses by doppler - R side fainter than L. All extremeties cool despite warm blankets.\n\nGI: Vomited ~ 100 cc partially digested food at 2200. Reglan given x 2. Later had dry heaves w/ turning. Hypoactive bowel sounds this AM.\n\nGU: Boarderline uop's all noc - > 30 cc/hr.\n\nEndo: On insulin gtt initially. Off for BS 76. Next elevated glucose treated w/ sliding scale. Gtt restarted and remains on, currently at 3.0 u/hr.\n\nPain: Good pain control w/ toradol. Additional MSO4 given sc x 2.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2131-03-08 00:00:00.000", "description": "Report", "row_id": 1544213, "text": "RESPIRATORY CARE:\nPT. EXTUBATED TO A 40% OFM. VENT PULLED.\nLOOKS GOOD. RR= 14 HR = 88 BP = 125/63.\n\n" }, { "category": "ECG", "chartdate": "2131-03-15 00:00:00.000", "description": "Report", "row_id": 291291, "text": "Sinus rhythm\nInferior T wave changes are nonspecific\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2131-03-15 00:00:00.000", "description": "Report", "row_id": 291292, "text": "Sinus rhythm\nPoor R wave progression\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2131-03-15 00:00:00.000", "description": "Report", "row_id": 291293, "text": "Sinus rhythm\nPoor R wave progression - probable normal variant\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2131-03-12 00:00:00.000", "description": "Report", "row_id": 291294, "text": "Sinus rhythm\nPoor R wave progression - probable normal variant\nNonspecific ST-T wave changes\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2131-03-08 00:00:00.000", "description": "Report", "row_id": 291295, "text": "Sinus rhythm\nPoor R wave progression - probable normal variant\nLateral T wave changes are nonspecific\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2131-03-05 00:00:00.000", "description": "Report", "row_id": 291296, "text": "Sinus rhythm. Left axis deviation. T wave inversion in lead aVL. Left atrial\nabnormality. Prolonged Q-T interval. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2115-08-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 481318, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n FEVER - 102.0\nF - 08:00 PM -> blood cultures sent\n asymptomatic sinus bradycardia into 40s while sleeping\n History obtained from Patient\n Allergies:\n History obtained from PatientAce Inhibitors\n Renal Toxicity;\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, chills\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: No(t) Cough, shortness of breath improved greatly\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37\nC (98.6\n HR: 46 (43 - 73) bpm\n BP: 135/39(63) {114/38(60) - 179/67(95)} mmHg\n RR: 17 (15 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 329 mL\n 416 mL\n PO:\n 240 mL\n 340 mL\n TF:\n IVF:\n 89 mL\n 76 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 740 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -411 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: Systolic), II/VI holosystolic at RUSB and\n apex\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, Wheezes : occl exp wheeze on left)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, mid-leg bilat, chronic venous stasis changes\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 232 K/uL\n 10.0 g/dL\n 106 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 47 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 7.7 K/uL\n [image002.jpg]\n 12:05 AM\n 05:43 AM\n WBC\n 7.7\n Hct\n 31.8\n Plt\n 232\n Cr\n 1.6\n TropT\n 0.19\n 0.15\n Glucose\n 106\n Other labs: PT / PTT / INR:25.5/123.4/2.5, CK / CKMB /\n Troponin-T:70//0.15, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n ASSESSMENT AND PLAN: 82yo M with h/o CAD s/p PCTA 15 years ago,\n diastolic CHF with h/o fluid overload on lasix, afib on coumadin with\n recent admission for retinal occlusion while on warfarin, now admitted\n with DOE, hypoxia, and fever.\n .\n # Hypoxia: Likely this is multifactorial. He has evidence of volume\n overload on exam, on CXR, and with his elevated BNP. In addition he has\n had fever and a questionable infiltrate on his CXR although he denies\n productive cough and sick contacts he could have PNA. PE is less likely\n since he is systemically anti-coagulated and he has other more likely\n etiologies for his hypoxia ( score 4). However, his INR was\n subtherapeutic on admission so this remains a possibility. Currently\n favor community-acquired PNA superimposed on mild diastolic CHF.\n - Will continue treatment for community acquired pneumonia with\n azithromycin and cetriaxone given the fever, hypoxia and possible\n infiltrates on CXR.\n - TTE showed new LV dilation likely causing more severe MR with\n preserved LVEF (although this is likely over-estimated in MR)\n consistent with acute exacerbation of his diastolic CHF. Will treat\n symptomatically with lasix with goal I/O of negative 1-2L today.\n - Will cycle cardiac enzymes to rule out acute coronary event although\n more likely the slight elevation is from stretch from fluid overload\n rather than ACS.\n - Daily I/O, weights\n - Low salt diet\n - Patient is unable to tolerate ACE-I or beta blockers ADRs in\n past. Will continue on current blood pressure regimen for afterload\n reduction with felodipine and hydralazine and continue statin and ASA\n - Non-invasive ventilation as needed to keep O2 sats >90%\n - LENIs today to r/o DVT as if he has a DVT while on coumadin he has\n technically failed anti-coagulation and may need IVC filter to avoid\n PEs.\n - Will hold off on CTA for PE as more likely diagnoses at this time and\n score < 4.\n - CXR today to evaluate for blossoming of the PNA and lessening of\n pulmonary edema with diuresis\n .\n # Fever: Most likely infectious with either pulmonary or urinary\n infection being most probable given leukocytosis, positive UA and\n hypoxia with CXR showing possible infiltrate.\n - Blood and urine cultures pending\n - attempt to obtain sputum culture\n - Continue to treat for CAP with CTX and azithromycin. be able to\n change to an oral regimen if stabilizes over next few days and cultures\n do not grow resistent organisms.\n - Will treat for UTI with ceftriaxone.\n - Follow up cultures and narrow antibiotics as able.\n .\n # CORONARIES: Patient has remote history of CAD s/p PTCA at OSH and\n currently has slightly elevated troponins with flat CKs and negative\n MBs in the setting of CRF. currently denies anginal symptoms although\n his SOB could be an anginal equivalent and it is possible that 3 days\n ago he had an acute event causing the acute exacerbation of his CHF.\n More likely, however, is that because of his infection he developed\n fluid overload and ventricular dilation causing troponin elevation that\n was not cleared his renal failure.\n - Will cycle cardiac enzymes.\n - ECG this morning\n - Continue asa, statin at home dose. Unable to tolerate beta blockers\n and ace inhibitors.\n .\n # PUMP: Patient has history of diastolic dysfunction and has had\n episodes of fluid overload treated with oral lasix in the past. TTE\n today revealed new LV dilation and likely as a result worsening of his\n MR . Unclear etiology of his new LV dilation although\n potentially infection vs late presentation of ACS.\n - Will treat acute exacerbation of diastolic CHF as above with lasix,\n daily weights, I/O, salt restricted diet and home medications\n - Goal I/O 2L over 24 hours\n .\n # RHYTHM: currently in slow afib with some EKGs looking like wandering\n pacemaker and rate controlled in 50s. CHADS2 score 5.\n - Will continue calcium channel blocker as ADR with beta blocker\n - EKG this morning\n - heparin gtt given sub-therapeutic INR on admission and recent retinal\n artery occlusion (thought more likely to be plaque not embolic from\n heart per notes but no documentation from OSH where diagnosed so\n unclear and thus higher risk patient than average AFib)\n - continue coumadin 5mg for now as starting on abx and likely to\n increase coumadin level so no need for increasing his home dose now.\n - check daily INRs\n .\n # Hypertension: Patient's BP was 170/70 at recent PCP visit and has\n been dificult to control according to OMR notes for last several years.\n Unable to tolerate ACE inhibitors or beta blockers\n - Will continue hydral/Imdur for afterload reduction\n - Will continue CCB\n - Will continue clonidine given rebound effect with daily dosing\n - nitro gtt if hypertensive and acutely sob although on floor patient\n reportedly had precipitous drop in BP when this was attempted.\n .\n # Chronic renal insufficiency: Currently patient is below his baseline\n creatinine of 1.7.\n - Will continue home regimen and follow creatinines daily\n .\n # Hyperlipidemia: As above will continue home dose of statin.\n .\n # Gout: Will continue home dose of allopurinol\n FEN: No IVF, E- replete PRN, N- hh/low salt\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with coumadin and hep gtt until inr therapeutic\n -Pain management with apap\n -Bowel regimen with colace, senna\n CODE: DNR/DNI confirmed on admission with patient and family\n CONTACT: Wife ; Son \n O: CCU pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2115-08-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 481321, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n FEVER - 102.0\nF - 08:00 PM -> blood cultures sent\n asymptomatic sinus bradycardia into 40s while sleeping\n History obtained from Patient\n Allergies:\n History obtained from PatientAce Inhibitors\n Renal Toxicity;\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, chills\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: No(t) Cough, shortness of breath improved greatly\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37\nC (98.6\n HR: 46 (43 - 73) bpm\n BP: 135/39(63) {114/38(60) - 179/67(95)} mmHg\n RR: 17 (15 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 329 mL\n 416 mL\n PO:\n 240 mL\n 340 mL\n TF:\n IVF:\n 89 mL\n 76 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 740 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -411 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: Systolic), II/VI holosystolic at RUSB and\n apex\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, Wheezes : occl exp wheeze on left)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, mid-leg bilat, chronic venous stasis changes\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 232 K/uL\n 10.0 g/dL\n 106 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 47 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 7.7 K/uL\n [image002.jpg]\n 12:05 AM\n 05:43 AM\n WBC\n 7.7\n Hct\n 31.8\n Plt\n 232\n Cr\n 1.6\n TropT\n 0.19\n 0.15\n Glucose\n 106\n Other labs: PT / PTT / INR:25.5/123.4/2.5, CK / CKMB /\n Troponin-T:70//0.15, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n ASSESSMENT AND PLAN: 82yo M with h/o CAD s/p PCTA 15 years ago,\n diastolic CHF with h/o fluid overload on lasix, afib on coumadin with\n recent admission for retinal occlusion while on warfarin, now admitted\n with DOE, hypoxia, and fever.\n .\n # Hypoxia: Likely this is multifactorial. He has evidence of volume\n overload on exam, on CXR, and with his elevated BNP. In addition he has\n had fever and a questionable infiltrate on his CXR although he denies\n productive cough and sick contacts he could have PNA. PE is less likely\n since he is systemically anti-coagulated and he has other more likely\n etiologies for his hypoxia ( score 4). However, his INR was\n subtherapeutic on admission so this remains a possibility. Currently\n favor community-acquired PNA superimposed on mild diastolic CHF.\n - Will continue treatment for community acquired pneumonia with\n azithromycin and cetriaxone given the fever, hypoxia and possible\n infiltrates on CXR.\n - TTE showed new LV dilation likely causing more severe MR with\n preserved LVEF (although this is likely over-estimated in MR)\n consistent with acute exacerbation of his diastolic CHF. Will treat\n symptomatically with lasix with goal I/O of negative 1-2L today.\n - Will cycle cardiac enzymes to rule out acute coronary event although\n more likely the slight elevation is from stretch from fluid overload\n rather than ACS.\n - Daily I/O, weights\n - Low salt diet\n - Patient is unable to tolerate ACE-I or beta blockers ADRs in\n past. Will continue on current blood pressure regimen for afterload\n reduction with felodipine and hydralazine and continue statin and ASA\n - Non-invasive ventilation as needed to keep O2 sats >90%\n - LENIs today to r/o DVT as if he has a DVT while on coumadin he has\n technically failed anti-coagulation and may need IVC filter to avoid\n PEs.\n - Will hold off on CTA for PE as more likely diagnoses at this time and\n score < 4.\n - CXR today to evaluate for blossoming of the PNA and lessening of\n pulmonary edema with diuresis -> evidence of LLL vs LUL infiltrate on\n AP portable today\n .\n # Fever: Most likely infectious with either pulmonary or urinary\n infection being most probable given leukocytosis, positive UA and\n hypoxia with CXR showing possible infiltrate.\n - Blood and urine cultures pending\n - attempt to obtain sputum culture\n - Continue to treat for CAP with CTX and azithromycin. be able to\n change to an oral regimen if stabilizes over next few days and cultures\n do not grow resistent organisms.\n - Will treat for UTI with ceftriaxone.\n - Follow up cultures and narrow antibiotics as able.\n .\n # CORONARIES: Patient has remote history of CAD s/p PTCA at OSH and\n currently has slightly elevated troponins with flat CKs and negative\n MBs in the setting of CRF. currently denies anginal symptoms although\n his SOB could be an anginal equivalent and it is possible that 3 days\n ago he had an acute event causing the acute exacerbation of his CHF.\n More likely, however, is that because of his infection he developed\n fluid overload and ventricular dilation causing troponin elevation that\n was not cleared his renal failure.\n - Will cycle cardiac enzymes.\n - ECG this morning\n - Continue asa, statin at home dose. Unable to tolerate beta blockers\n and ace inhibitors.\n .\n # PUMP: Patient has history of diastolic dysfunction and has had\n episodes of fluid overload treated with oral lasix in the past. TTE\n today revealed new LV dilation and likely as a result worsening of his\n MR . Unclear etiology of his new LV dilation although\n potentially infection vs late presentation of ACS.\n - Will treat acute exacerbation of diastolic CHF as above with lasix,\n daily weights, I/O, salt restricted diet and home medications\n - Goal I/O 2L over 24 hours\n .\n # RHYTHM: currently in slow afib with some EKGs looking like wandering\n pacemaker and rate controlled in 50s. CHADS2 score 5. Pt has\n asymptomatic bradycardia, with evidence of AV delay and Wenkebach on\n ECGs.\n - Will continue calcium channel blocker as ADR with beta blocker\n - EKG this morning\n - heparin gtt given sub-therapeutic INR on admission and recent retinal\n artery occlusion (thought more likely to be plaque not embolic from\n heart per notes but no documentation from OSH where diagnosed so\n unclear and thus higher risk patient than average AFib)\n - continue coumadin 5mg for now as starting on abx and likely to\n increase coumadin level so no need for increasing his home dose now.\n - check daily INRs\n .\n # Hypertension: Patient's BP was 170/70 at recent PCP visit and has\n been dificult to control according to OMR notes for last several years.\n Unable to tolerate ACE inhibitors or beta blockers\n - Will continue hydral/Imdur for afterload reduction\n - Will continue CCB\n - Will continue clonidine given rebound effect with daily dosing\n - nitro gtt if hypertensive and acutely sob although on floor patient\n reportedly had precipitous drop in BP when this was attempted.\n .\n # Chronic renal insufficiency: Currently patient is below his baseline\n creatinine of 1.7.\n - Will continue home regimen and follow creatinines daily\n .\n # Hyperlipidemia: As above will continue home dose of statin.\n .\n # Gout: Will continue home dose of allopurinol\n FEN: No IVF, E- replete PRN, N- hh/low salt\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with coumadin and hep gtt until inr therapeutic\n -Pain management with apap\n -Bowel regimen with colace, senna\n CODE: DNR/DNI confirmed on admission with patient and family\n CONTACT: Wife ; Son \n O: CCU pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2115-08-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 481323, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n FEVER - 102.0\nF - 08:00 PM -> blood cultures sent\n asymptomatic sinus bradycardia into 40s while sleeping\n History obtained from Patient\n Allergies:\n History obtained from PatientAce Inhibitors\n Renal Toxicity;\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, chills\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: No(t) Cough, shortness of breath improved greatly\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37\nC (98.6\n HR: 46 (43 - 73) bpm\n BP: 135/39(63) {114/38(60) - 179/67(95)} mmHg\n RR: 17 (15 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 329 mL\n 416 mL\n PO:\n 240 mL\n 340 mL\n TF:\n IVF:\n 89 mL\n 76 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 740 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -411 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: Systolic), II/VI holosystolic at RUSB and\n apex\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, Wheezes : occl exp wheeze on left)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, mid-leg bilat, chronic venous stasis changes\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 232 K/uL\n 10.0 g/dL\n 106 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 47 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 7.7 K/uL\n [image002.jpg]\n 12:05 AM\n 05:43 AM\n WBC\n 7.7\n Hct\n 31.8\n Plt\n 232\n Cr\n 1.6\n TropT\n 0.19\n 0.15\n Glucose\n 106\n Other labs: PT / PTT / INR:25.5/123.4/2.5, CK / CKMB /\n Troponin-T:70//0.15, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n ASSESSMENT AND PLAN: 82yo M with h/o CAD s/p PCTA 15 years ago,\n diastolic CHF with h/o fluid overload on lasix, afib on coumadin with\n recent admission for retinal occlusion while on warfarin, now admitted\n with DOE, hypoxia, and fever.\n .\n # Hypoxia: Likely this is multifactorial. He has evidence of volume\n overload on exam, on CXR, and with his elevated BNP. In addition he has\n had fever and a questionable infiltrate on his CXR although he denies\n productive cough and sick contacts he could have PNA. PE is less likely\n since he is systemically anti-coagulated and he has other more likely\n etiologies for his hypoxia ( score 4). However, his INR was\n subtherapeutic on admission so this remains a possibility. Currently\n favor community-acquired PNA superimposed on mild diastolic CHF.\n - Will continue treatment for community acquired pneumonia with\n azithromycin and cetriaxone given the fever, hypoxia and possible\n infiltrates on CXR.\n - TTE showed new LV dilation likely causing more severe MR with\n preserved LVEF (although this is likely over-estimated in MR)\n consistent with acute exacerbation of his diastolic CHF. Will treat\n symptomatically with lasix with goal I/O of negative 1-2L today.\n - Will cycle cardiac enzymes to rule out acute coronary event although\n more likely the slight elevation is from stretch from fluid overload\n rather than ACS.\n - Daily I/O, weights\n - Low salt diet\n - Patient is unable to tolerate ACE-I or beta blockers ADRs in\n past. Will continue on current blood pressure regimen for afterload\n reduction with felodipine and hydralazine and continue statin and ASA\n - Non-invasive ventilation as needed to keep O2 sats >90%\n - LENIs today to r/o DVT as if he has a DVT while on coumadin he has\n technically failed anti-coagulation and may need IVC filter to avoid\n PEs.\n - Will hold off on CTA for PE as more likely diagnoses at this time and\n score < 4.\n - CXR today to evaluate for blossoming of the PNA and lessening of\n pulmonary edema with diuresis -> evidence of LLL vs LUL infiltrate on\n AP portable today\n .\n # Fever: Most likely infectious with either pulmonary or urinary\n infection being most probable given leukocytosis, positive UA and\n hypoxia with CXR showing possible infiltrate.\n - Blood and urine cultures pending\n - attempt to obtain sputum culture\n - Continue to treat for CAP with CTX and azithromycin. be able to\n change to an oral regimen if stabilizes over next few days and cultures\n do not grow resistent organisms.\n - Will treat for UTI with ceftriaxone.\n - Follow up cultures and narrow antibiotics as able.\n .\n # CORONARIES: Patient has remote history of CAD s/p PTCA at OSH and\n currently has slightly elevated troponins with flat CKs and negative\n MBs in the setting of CRF. currently denies anginal symptoms although\n his SOB could be an anginal equivalent and it is possible that 3 days\n ago he had an acute event causing the acute exacerbation of his CHF.\n More likely, however, is that because of his infection he developed\n fluid overload and ventricular dilation causing troponin elevation that\n was not cleared his renal failure.\n - Will cycle cardiac enzymes.\n - ECG this morning\n - Continue asa, statin at home dose. Unable to tolerate beta blockers\n and ace inhibitors.\n .\n # PUMP: Patient has history of diastolic dysfunction and has had\n episodes of fluid overload treated with oral lasix in the past. TTE\n today revealed new LV dilation and likely as a result worsening of his\n MR . Unclear etiology of his new LV dilation although\n potentially infection vs late presentation of ACS.\n - Will treat acute exacerbation of diastolic CHF as above with lasix,\n daily weights, I/O, salt restricted diet and home medications\n - Goal I/O 2L over 24 hours\n .\n # RHYTHM: currently in slow afib with some EKGs looking like wandering\n pacemaker and rate controlled in 50s. CHADS2 score 5. Pt has\n asymptomatic bradycardia, with evidence of AV delay and Wenkebach on\n ECGs.\n - Will continue calcium channel blocker as ADR with beta blocker\n - EKG this morning\n - heparin gtt given sub-therapeutic INR on admission and recent retinal\n artery occlusion (thought more likely to be plaque not embolic from\n heart per notes but no documentation from OSH where diagnosed so\n unclear and thus higher risk patient than average AFib)\n - continue coumadin 5mg for now as starting on abx and likely to\n increase coumadin level so no need for increasing his home dose now.\n - check daily INRs\n .\n # Hypertension: Patient's BP was 170/70 at recent PCP visit and has\n been dificult to control according to OMR notes for last several years.\n Unable to tolerate ACE inhibitors or beta blockers\n - Will continue hydral/Imdur for afterload reduction\n - Will continue CCB\n - Will continue clonidine given rebound effect with daily dosing\n - nitro gtt if hypertensive and acutely sob although on floor patient\n reportedly had precipitous drop in BP when this was attempted.\n .\n # Chronic renal insufficiency: Currently patient is below his baseline\n creatinine of 1.7.\n - Will continue home regimen and follow creatinines daily\n .\n # Hyperlipidemia: As above will continue home dose of statin.\n .\n # Gout: Will continue home dose of allopurinol\n FEN: No IVF, E- replete PRN, N- hh/low salt\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with coumadin and hep gtt until inr therapeutic\n -Pain management with apap\n -Bowel regimen with colace, senna\n CODE: DNR/DNI confirmed on admission with patient and family\n CONTACT: Wife ; Son \n O: CCU pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Echo", "chartdate": "2115-08-20 00:00:00.000", "description": "Report", "row_id": 73993, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Left ventricular function.\nHeight: (in) 70\nWeight (lb): 185\nBSA (m2): 2.02 m2\nBP (mm Hg): 159/50\nHR (bpm): 52\nStatus: Inpatient\nDate/Time: at 15:18\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Top normal/borderline dilated LV cavity size. Overall normal\nLVEF (>55%). [Intrinsic LV systolic function likely depressed given the\nseverity of valvular regurgitation.]\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Eccentric MR jet.\nModerate to severe (3+) MR.\n\nTRICUSPID VALVE: Mild to moderate [+] TR. Severe PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The left ventricular cavity size is top\nnormal/borderline dilated. Overall left ventricular systolic function is\nnormal (LVEF>55%). [Intrinsic left ventricular systolic function is likely\nmore depressed given the severity of valvular regurgitation.] There may be\ninferolateral hypokinesis but views are technically suboptimal. Right\nventricular chamber size is normal. with normal free wall contractility. The\naortic valve leaflets (3) are mildly thickened. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. An eccentric, laterally\ndirected jet of moderate to severe (3+) mitral regurgitation is seen. There is\nsevere pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , mitral\nregurgitation is now more prominent. There may be inferolateral hypokinesis in\nthe current study but images are technically suboptimal for assessment of\nregional wall motion. The left ventricular cavity is now more dilated.\n\n\n" }, { "category": "ECG", "chartdate": "2115-08-20 00:00:00.000", "description": "Report", "row_id": 173040, "text": "The rhythm is difficult to ascertain. However, it could be sinus bradycardia\nwith prolonged A-V conduction and multiple premature atrial contractions.\nAtrial fibrillation cannot be excluded, although unlikely. Persistent\nST segment depressions in leads V4-V6 raise consideration of myocardial\nischemia. Prominent V wave in leads V3-V6 with prolonged Q-T interval. Clinical\ncorrelation is suggested.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2115-08-20 00:00:00.000", "description": "Report", "row_id": 173041, "text": "The rhythm appears to be more clearly atrial fibrillation with a slow\nventricular response. The ST segment abnormalities remain and the Q-T interval\nis prolonged.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2115-08-20 00:00:00.000", "description": "Report", "row_id": 173042, "text": "The rhythm is difficult to ascertain. It appears to be sinus with frequent\npremature atrial contractions. However, it could be atrial fibrillation with a\nslow ventricular conduction because of the irregularities of the QRS response.\nThe previously noted ST segment abnormalities remain with prolonged\nQ-T interval.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2115-08-20 00:00:00.000", "description": "Report", "row_id": 173043, "text": "Sinus rhythm with prolonged A-V conduction. A single premature atrial\ncontraction is noted. The previously noted ST segment depressions remain. The\nQ-T interval is prolonged. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2115-08-20 00:00:00.000", "description": "Report", "row_id": 173044, "text": "Probable sinus rhythm with prolonged A-V conduction. Significant ST segment\ndepressions in leads V4-V6 raising consideration of myocardial ischemia.\nPossible left ventricular hypertrophy.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2115-08-22 00:00:00.000", "description": "Report", "row_id": 173038, "text": "Probable atrial fibrillation with slow ventricular response. Occasional\npremature ventricular beats. QTc interval prolongation. Diffuse ST-T wave\nchanges which are non-specific. Compared to the previous tracing of \nventricular premature beats are new. Otherwise, no other significant\ndiagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2115-08-21 00:00:00.000", "description": "Report", "row_id": 173039, "text": "Sinus bradycardia. A-V conduction delay. Q-T interval prolongation. Compared to\nthe previous tracing of the T waves are now biphasic in\nleads II, III and aVF raising the question of active inferior myocardial\nischemic process. There is occasional junctional escape rhythm. Clinical\ncorrelation is suggested.\n\n" }, { "category": "Physician ", "chartdate": "2115-08-20 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 481202, "text": "Chief Complaint: SOB\n HPI:\n 82M with CAD, chronic diastolic CHF, AFib on coumadin admitted with\n dyspnea. Three days ago patient notes that he was not feeling well. He\n was more fatigued than usual and had shortness of breath with walking.\n He did not have palpitations, chest pain, fevers, chills, orthopnea,\n pnd, worse edema than baseline (has had chronic LE edema X 5 years),\n syncope, or presyncope. At about 3 am on the morning of admission he\n awoke to turn down the AC because he was chilly. When he sat up he\n became acutely short of breath. His wife was able to calm him down and\n when he lay back down he felt better. However, over the course of the\n next few hours he started to feel more and more short of breath, even\n when lying down, and by 7am his wife was very concerned. She noticed\n that when she tried to stand him up to walk to the living room he was\n very weak and his legs were wobbly. She called 911, and they brought\n him to the ED.\n .\n Upon presentation to the ED initial vitals were: T 98 HR 76 BP 179/68\n RR 28 SP02 98%RA. In the ED patient denied CP, fever, chills, cough,\n weight gain. His O2 sats declined from 98% on RA ->91% on 4L->96% on\n NRB. CXR showed mild fluid overload and possible PNA. Bedside TTE\n revealed:\n The left atrium is moderately dilated. There is mild symmetric left\n ventricular hypertrophy. The left ventricular cavity size is normal.\n Overall left ventricular systolic function is normal (LVEF 70%). There\n is no ventricular septal defect. Right ventricular chamber size and\n free wall motion are normal. The ascending aorta is mildly dilated.\n There are focal calcifications in the aortic arch. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No aortic regurgitation is seen. The mitral valve leaflets are mildly\n thickened. There is no mitral valve prolapse. Mild (1+) mitral\n regurgitation is seen. The estimated pulmonary\n artery systolic pressure is normal. There is no pericardial effusion.\n .\n Compared with the findings of the prior study (images reviewed) of , the findings are similar.\n .\n He received the following medications: Aspirin 81mg, CeftriaXONE 1g,\n Azithromycin 500mg, Nitroglycerin SL 0.4mg SLX3 (for HF not for\n complaints of CP), and Furosemide 80mg IV X 1. He felt better after the\n furosemide (he put out 500mL) and his O2 requirement came down to 94%\n on 4L. He was transferred to the floor.\n .\n On the floor patient remained on NC and then on first set of vitals was\n noted to be hypoxic to the mid-80s on 5L NC. He was placed on a NRB and\n his O2 sat came up to 100%. He had no complaints of chest pain,\n palpitations, shortness of breath, abdominal pain, nausea, vomiting, or\n cough at the time. His EKG was unchanged from prior. A CXR was also\n unchanged. ABG showed an elevated A-a gradient with PO2 103 on the NRB.\n He was given another 80mg IV lasix, morphine, and started on nitro\n paste. Intially he improved with this regimen, however, he would\n occasionally dip into the high 80s and then recover spontaneously on\n the NRB and they were unable to wean him off the NRB. He was\n transferred to the CCU for his continued requirement of the NRB.\n .\n On presentation to the ccu the patient was comfortable on a NC. He\n denied fevers, chills, palpitations, chest pain, nausea, vomiting,\n diaphoresis, abdominal pain, bloating, worsening edema, weight gain,\n diarrhea, and dysuria. He endorsed shortness of breath as outlined\n above although currently less than prior, constipation off and on for\n several years, and chronic edema of his lower extremities for the last\n 5 years - treated with lasix.\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n Ace Inhibitors\n Renal Toxicity;\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,650 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS (confirmed with patient's wife and pharmacy)\n ALLOPURINOL 300 mg daily\n CLONIDINE 0.1 mg twice daily\n FELODIPINE 10 mg daily\n FUROSEMIDE 80 mg daily\n HYDRALAZINE 150 mg TID\n IMDUR 60 mg daily\n SIMVASTATIN 40 mg daily\n WARFARIN 5 mg daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: hypertension, dyslipidemia.\n 2. CARDIAC HISTORY:\n -CABG: None\n -PERCUTANEOUS CORONARY INTERVENTIONS: s/p PTCA x 1 15 years ago\n records not at the \n -PACING/ICD: none\n 3. OTHER PAST MEDICAL HISTORY:\n GASTRITIS\n H.pylori + (treated)\n GOUT\n SYNCOPE\n RENAL INSUFFICIENCY (creat ~ 1.6)\n VENOUS INSUFFICIENCY and lower extremity edema\n BENIGN PROSTATIC HYPERTROPHY\n ATRIAL FIBRILLATION\n diastolic dysfunction with volume overload treated with lasix\n RETINAL VASCULAR OCCLUSION in thought plaque rupture not\n thrombotic event as therapeutic on coumadin at the time\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death; otherwise non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Originally from Poland. Worked in labor camp for a few\n years before emmigrating. Also was in the service in the US. Lives in\n , MA with his wife. history: Former 15 pack-year smoker,\n quit 60 years ago. Rare ETOH use. No recent travel. No sick contacts.\n Review of systems:\n Flowsheet Data as of 08:53 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 55 (55 - 73) bpm\n BP: 143/49(73) {143/49(73) - 179/67(95)} mmHg\n RR: 23 (19 - 25) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 36 mL\n PO:\n TF:\n IVF:\n 36 mL\n Blood products:\n Total out:\n 0 mL\n 620 mL\n Urine:\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -584 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n V/S: Wt 89.4 kg T 99.5->102 ax BP 170/71 HR 70 RR 22 O2sat 94%6L NC\n GENERAL: WDWN M in NAD. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or\n cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP to angle of jaw\n CARDIAC: PMI located in 5th intercostal space, midclavicular line.\n irregularly irregular with distant heart sounds. No m/r/g.\n LUNGS: Resp were unlabored, no accessory muscle use. Scattered\n expiratory wheezes with poor air movement bilaterally and crackles\n about of the way up bilaterally.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits. Umbilical hernia without tenderness.\n EXTREMITIES: 1+ edema bilaterally to knees. Negative homans sign.\n NEURO: Alert and oriented X 3. Right pupil larger than left. Left arm\n slightly weaker than right.\n Labs / Radiology\n WBC: 8.7\n Hgb: 10.7\n Hct: 34.4 (stable)\n Plt: 214\n N:89.6 L:6.0 M:4.1 E:0.3 Bas:0.1\n .\n PT: 20.1 PTT: 32.0 INR: 1.9\n .\n Na: 139\n Cl: 101\n BUN: 45\n Glucose: 172 AGap=19\n Potassium: 4.1\n Bicarb: 23\n Creatinine: 1.7 (2.2 in )\n Trop: 0.06 -> 0.11\n CK: 68 ->76 MB: Notdone X 2\n proBNP: 2736 (prior 2100)\n Imaging:\n ECHO\n : The left atrium is moderately dilated. There is mild symmetric\n left ventricular hypertrophy. The left ventricular cavity size is\n normal. Overall left ventricular systolic function is normal (LVEF\n 70%). There is no ventricular septal defect. Right ventricular chamber\n size and free wall motion are normal. The ascending aorta is mildly\n dilated. There are focal calcifications in the aortic arch. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\n regurgitation is seen. The estimated pulmonary artery systolic pressure\n is normal. There is no pericardial effusion.\n TTE on floor: The left atrium is mildly dilated. The left\n ventricular cavity size is top normal/borderline dilated. Overall left\n ventricular systolic function is normal (LVEF>55%). [Intrinsic left\n ventricular systolic function is likely more depressed given the\n severity of valvular regurgitation.] There may be inferolateral\n hypokinesis but views are technically suboptimal. Right ventricular\n chamber size is normal. with normal free wall contractility. The aortic\n valve leaflets (3) are mildly thickened. No aortic regurgitation is\n seen. The mitral valve leaflets are mildly thickened. An eccentric,\n laterally directed jet of moderate to severe (3+) mitral regurgitation\n is seen. There is severe pulmonary artery systolic hypertension. There\n is no pericardial effusion.\n Compared with the prior study (images reviewed) of , mitral\n regurgitation is now more prominent. There may be inferolateral\n hypokinesis in the current study but images are technically suboptimal\n for assessment of regional wall motion. The left ventricular cavity is\n now more dilated.\n CXR in ED : Bilateral perihilar opacities are noted.\n There is a tiny right pleural effusion. No pneumothorax is seen. The\n heart is mildly enlarged. The aorta is calcified and tortuous.\n Degenerative changes of the spine are noted.\n IMPRESSION:\n Bilateral perihilar opacities may represent congestive heart failure\n versus pneumonia. In the setting of the patient's elevated BNP,\n findings more likely represent moderate congestive heart failure.\n CXR on floor : Bilateral peri-hilar opacities and unchanged\n cardiomegaly. No change from prior CXR from same day.\n Microbiology: UA: Positive for bacteria, blood and RBC\n ECG: EKG @ 0923 AFib 49 bpm nl axis 1-\n depressions V3-V6 QTc elevation or T-wave inversion\n Assessment and Plan\n ASSESSMENT AND PLAN: 82yo M with h/o CAD s/p PCTA 15 years ago,\n diastolic CHF with h/o fluid overload on lasix, afib on coumadin with\n recent admission for retinal occlusion while on warfarin, now admitted\n with DOE, hypoxia, and fever.\n # Hypoxia: Likely this is multifactorial. He has evidence of volume\n overload on exam, on CXR, and with his elevated BNP. In addition he has\n had fever and a questionable infiltrate on his CXR although he denies\n productive cough and sick contacts he could have PNA. PE is less likely\n since he is systemically anti-coagulated and he has other more likely\n etiologies for his hypoxia ( score 4). However, his INR was\n subtherapeutic on admission so this remains a possibility.\n - Will continue treatment for community acquired pneumonia with\n azithromycin and cetriaxone given the fever, hypoxia and possible\n infiltrates on CXR.\n - TTE showed new LV dilation likely causing more severe MR with\n preserved LVEF (although this is likely over-estimated in MR)\n consistent with acute exacerbation of his diastolic CHF. Will treat\n symptomatically with lasix with goal I/O of negative 1-2L today.\n - Will cycle cardiac enzymes to rule out acute coronary event although\n more likely the slight elevation is from stretch from fluid overload\n rather than ACS.\n - Daily I/O, weights\n - Low salt diet\n - Patient is unable to tolerate ACE-I or beta blockers ADRs in\n past. Will continue on current blood pressure regimen for afterload\n reduction with felodipine and hydralazine and continue statin and ASA\n - Non-invasive ventilation as needed to keep O2 sats >90%\n - LENIs in am to r/o DVT as if he has a DVT while on coumadin he has\n technically failed anti-coagulation and may need IVC filter to avoid\n PEs.\n - Will hold off on CTA for PE as more likely diagnoses at this time and\n score only 4.\n - CXR in am to evaluate for blossoming of the PNA and lessening of\n pulmonary edema with diuresis\n # Fever: Most likely infectious with either pulmonary or urinary\n infection being most probable given leukocytosis, positive UA and\n hypoxia with CXR showing possible infiltrate.\n - Blood and urine cultures pending\n - attempt to obtain sputum culture\n - Continue to treat for CAP with CTX and azithromycin. be able to\n change to an oral regimen if stabilizes over next few days and cultures\n do not grow resistent organisms.\n - Will treat for UTI with ceftriaxone.\n - Follow up cultures and narrow antibiotics as able.\n # CORONARIES: Patient has remote history of CAD s/p PTCA at OSH and\n currently has slightly elevated troponins with flat CKs and negative\n MBs in the setting of CRF. currently denies anginal symptoms although\n his SOB could be an anginal equivalent and it is possible that 3 days\n ago he had an acute event causing the acute exacerbation of his CHF.\n More likely, however, is that because of his infection he developed\n fluid overload and ventricular dilation causing troponin elevation that\n was not cleared his renal failure.\n - Will cycle cardiac enzymes.\n - AM EKG\n - Continue asa, statin at home dose. Unable to tolerate beta blockers\n and ace inhibitors.\n # PUMP: Patient has history of diastolic dysfunction and has had\n episodes of fluid overload treated with oral lasix in the past. TTE\n today revealed new LV dilation and likely as a result worsening of his\n MR . Unclear etiology of his new LV dilation although\n potentially infection vs late presentation of ACS.\n - Will treat acute exacerbation of diastolic CHF as above with lasix,\n daily weights, I/O, salt restricted diet and home medications\n - Goal I/O 2L over 24 hours\n # RHYTHM: currently in slow afib with some EKGs looking like wandering\n pacemaker and rate controlled in 50s. CHADS2 score 5.\n - Will continue calcium channel blocker as ADR with beta blocker\n - EKG in am\n - heparin gtt given sub-therapeutic INR on admission and recent retinal\n artery occlusion (thought more likely to be plaque not embolic from\n heart per notes but no documentation from OSH where diagnosed so\n unclear and thus higher risk patient than average AFib)\n - continue coumadin 5mg for now as starting on abx and likely to\n increase coumadin level so no need for increasing his home dose now.\n - check daily INRs\n # Hypertension: Patient's BP was 170/70 at recent PCP visit and has\n been dificult to control according to OMR notes for last several years.\n Unable to tolerate ACE inhibitors or beta blockers\n - Will continue hydral/Imdur for afterload reduction\n - Will continue CCB\n - Will continue clonidine given rebound effect with daily dosing\n - Consider nitro gtt if hypertensive and acutely sob overnight although\n on floor patient reportedly had precipitous drop in BP when this was\n attempted.\n # Chronic renal insufficiency: Currently patient is below his baseline\n creatinine of 1.7.\n - Will continue home regimen and follow creatinines daily\n # Hyperlipidemia: As above will continue home dose of statin.\n .\n # Gout: Will continue home dose of allopurinol\n FEN: No IVF, E- replete PRN, N- HH/low salt\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with coumadin and hep gtt until inr therapeutic\n -Pain management with apap\n -Bowel regimen with colace, senna\n CODE: DNR/DNI confirmed on admission with patient and family\n CONTACT: Wife ; Son \n O: CCU pending above\n ICU Care\n Nutrition: HH/low salt\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt, Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2115-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 481198, "text": "82 YR OLD C H/O CHF CAME TO ED BY AMBULANCE EARLY THIS AM C SEVERAL DAY\n OF SOB . 80 MG LASIX GIVEN X2 ,DIURESED 2.5 L .WEANED FROM NON\n REBREATHER TO 6L NP .ALSO GIVEN CEFTRIAXONE,AZITHROMYCIN .PT\n ,STARTED ON LOW DOSE NITRO BUT BP COULD NOT TOLERATE IT\n .HX AFIB,ON COUMADIN AFTER STROKE IN R PUPIL LARGER THAN LEFT,L ARM\n HAS DECREASED RANGE OF MOTION DUE TO FALL ON ICE IN \n WEAKER,ANGIOPLASTY 10 YRS AGO .HAS RENAL INSUFFICENCY .DESPITE DIURESIS\n PT REMAINS HYPOXIC TO CCU FOR FURTHER TX,CHF /? PNA\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PT ALERT,OX3,DENIES CP,SOME SOB BUT APPEARS FAIRLY COMFORTABLE\n .DIURESING FROM LASIX GIVEN ON F3 ,CRACKLES IN BASES ,6LNP. SAT 93. IN\n AFIB HR 60S. TO 179/67 .T 99.8\n Action:\n HEPARIN DRIP STARTED.ANTIHYPERTENSIVES STARTED . FAMILY AND PT ORIENTED\n TO UNIT AND UPDATED AS TO PLAN BY NURSE \n Response:\n PT MEDS\n Plan:\n TITRATE ANTIHYPERTENSIVES ,ADD IV NITRO IF NEEDED , CHECK PTT 6HR\n ,MONITOR FLUID STATUS,LYTES ,NEURO STATUS,WILL HAVE NONINVASIVES IN USN\n TOMORROW\n" }, { "category": "Nursing", "chartdate": "2115-08-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 481176, "text": "82 YR OLD C H/O CHF CAME TO ED BY AMBULANCE EARLY THIS AM C SEVERAL DAY\n OF SOB . 80 MG LASIX GIVEN X2 ,DIURESED 2.5 L .WEANED FROM NON\n REBREATHER TO 6L NP .ALSO GIVEN CEFTRIAXONE,AZITHROMYCIN .PT\n ,STARTED ON LOW DOSE NITRO BUT BP COULD NOT TOLERATE IT\n .HX AFIB,ON COUMADIN AFTER STROKE IN ,ANGIOPLASTY 10 YRS AGO .HAS\n RENAL INSUFFICENCY .DESPITE DIURESIS PT REMAINS HYPOXIC\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2115-08-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 481370, "text": "Pt is an 82yo M (DNR/DNI) with h/o CAD s/p PCTA 15 years ago, diastolic\n CHF with h/o fluid overload on lasix, afib on coumadin with recent\n admission for retinal occlusion while on warfarin. Pt now admitted on\n with c/o DOE, hypoxia and fevers to 102. BC x2/ urine cx sent.\n Given 80mg lasix x2, voided >2.5L. INR sub-therapeutic on coumadin,\n started on heparin gtt. Poss UTI, tnsf to CCU. He had evidence of\n volume overload on CXR, in addition of fever and questionable\n infiltrate. Denies productive cough and sick contacts but could have\n community acquired PNA superimposed on mild diastolic CHF. Slight\n concern for PE w/ Afib & subtherapeutic INR. Will continue treatment\n for community acquired pneumonia with azithromycin and cetriaxone. \n CXR improved p diuresis, currently on 4L nc sats> 94%, lung sounds\n faint crackles bibasilary. Tele Afib 46-60, BPs 130s-140s. Heparin gtt\n conts at 950 units/hr, next PTT due at 3pm. Currently Afeb, all\n cultures pending. TTE showed known 3+ MR/ diastolic dysfunction, no\n atrial clots. Had LENI\ns to r/o DVTs, results pending. Repleated K+/\n Mg+, no further diuresis.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 89.4 kg\n Daily weight:\n Allergies/Reactions:\n Ace Inhibitors\n Renal Toxicity;\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CAD, CHF, CVA, Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:146\n D:45\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95 %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 512 mL\n 24h total out:\n 655 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 05:43 AM\n Potassium:\n 3.7 mEq/L\n 05:43 AM\n Chloride:\n 104 mEq/L\n 05:43 AM\n CO2:\n 26 mEq/L\n 05:43 AM\n BUN:\n 47 mg/dL\n 05:43 AM\n Creatinine:\n 1.6 mg/dL\n 05:43 AM\n Glucose:\n 106 mg/dL\n 05:43 AM\n Hematocrit:\n 31.8 %\n 05:43 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 1400\n" }, { "category": "Nursing", "chartdate": "2115-08-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 481364, "text": "Pt is an 82yo M (DNR/DNI) with h/o CAD s/p PCTA 15 years ago, diastolic\n CHF with h/o fluid overload on lasix, afib on coumadin with recent\n admission for retinal occlusion while on warfarin. Pt now admitted on\n with c/o DOE, hypoxia and fevers to 102. BC x2/ urine cx sent.\n Given 80mg lasix x2, voided >2.5L. INR subtherapeutic on coumadin,\n started on heparin gtt. Poss UTI, tnsf to CCU. He had evidence of\n volume overload on CXR, in addition he had a fever and questionable\n infiltrate. Denies productive cough and sick contacts but could have\n community acquired PNA superimposed on mild diastolic CHF. Slight\n concern for PE w/ Afib & subtherapeutic INR. Will continue treatment\n for community acquired pneumonia with azithromycin and cetriaxone. \n CXR improved p diuresis, currently on 4L nc sats> 94%, lung sounds\n faint crackles bibasilary. Tele Afib 48-60, BPs 130s-140s. Heparin gtt\n conts at 950 units/hr, currently Afeb, all cultures pending. TTE\n showed known severe MR/ diastolic dysfunction, no atrial clots. Had\n LENI\ns to r/o DVTs, results pending.\n" }, { "category": "Nursing", "chartdate": "2115-08-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 481363, "text": "Pt is an 82yo M (DNR/DNI) with h/o CAD s/p PCTA 15 years ago, diastolic\n CHF with h/o fluid overload on lasix, afib on coumadin with recent\n admission for retinal occlusion while on warfarin. Pt now admitted on\n with c/o DOE, hypoxia and fevers to 102. BC x2/ urine cx sent.\n Given 80mg lasix x2, voided >2.5L. INR subtherapeutic on coumadin,\n started on heparin gtt. Poss UTI, tnsf to CCU. He had evidence of\n volume overload on CXR, in addition he had a fever and questionable\n infiltrate. Denies productive cough and sick contacts but could have\n community acquired PNA superimposed on mild diastolic CHF. Slight\n concern for PE w/ Afib & subtherapeutic INR. Will continue treatment\n for community acquired pneumonia with azithromycin and cetriaxone. \n CXR improved p diuresis, currently on 4L nc sats> 94%, lung sounds\n faint crackles bibasilary. Tele Afib 48-60, BPs 130s-140s. Heparin gtt\n conts at 950 units/hr, currently Afeb, all cultures pending. Had\n LENI\ns done this am, results pending.\n" }, { "category": "Nursing", "chartdate": "2115-08-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 481358, "text": "Pt is an 82yo M (DNR/DNI) with h/o CAD s/p PCTA 15 years ago, diastolic\n CHF with h/o fluid overload on lasix, afib on coumadin with recent\n admission for retinal occlusion while on warfarin. Pt now admitted on\n with c/o DOE, hypoxia and fevers to 102. BC x2/ urine cx sent.\n Given 80mg lasix x2, voided >2.5L. INR subtherapeutic on coumadin,\n started on heparin gtt. On Ceftriaxone & Azithromycin for prob UTI & ?\n PNA. tnsf to CCU on 100% NRB. Weaned to 4L nc sats >94%. CXR much\n improved.\n" }, { "category": "Nursing", "chartdate": "2115-08-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 481359, "text": "Pt is an 82yo M (DNR/DNI) with h/o CAD s/p PCTA 15 years ago, diastolic\n CHF with h/o fluid overload on lasix, afib on coumadin with recent\n admission for retinal occlusion while on warfarin. Pt now admitted on\n with c/o DOE, hypoxia and fevers to 102. BC x2/ urine cx sent.\n Given 80mg lasix x2, voided >2.5L. INR subtherapeutic on coumadin,\n started on heparin gtt. On Ceftriaxone & Azithromycin for prob UTI & ?\n PNA. tnsf to CCU on 100% NRB. He had evidence of volume overload on\n CXR, in addition he had a fever and questionable infiltrate on his CXR.\n Denies productive cough and sick contacts but could have CA PNA.\n" }, { "category": "Nursing", "chartdate": "2115-08-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 481360, "text": "Pt is an 82yo M (DNR/DNI) with h/o CAD s/p PCTA 15 years ago, diastolic\n CHF with h/o fluid overload on lasix, afib on coumadin with recent\n admission for retinal occlusion while on warfarin. Pt now admitted on\n with c/o DOE, hypoxia and fevers to 102. BC x2/ urine cx sent.\n Given 80mg lasix x2, voided >2.5L. INR subtherapeutic on coumadin,\n started on heparin gtt. Poss UTI, tnsf to CCU. He had evidence of\n volume overload on CXR, in addition he had a fever and questionable\n infiltrate on his CXR. Denies productive cough and sick contacts but\n could have community acquired PNA superimposed on mild diastolic CHF.\n Will continue treatment for community acquired pneumonia with\n azithromycin and cetriaxone. CXR improved p diuresis, currently on\n 4L nc sats> 94% Heparin gtt conts at 950 units/hr. Afeb\n" }, { "category": "Nursing", "chartdate": "2115-08-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 481232, "text": "82 YR OLD C H/O CHF CAME TO ED C SEVERAL DAY OF SOB . 80 MG LASIX\n GIVEN X2 ,DIURESED 2.5 L .WEANED FROM NON REBREATHER TO 6L NP .ALSO\n GIVEN CEFTRIAXONE,AZITHROMYCIN .PT ,STARTED ON LOW DOSE\n NITRO BUT BP COULD NOT TOLERATE IT .HX AFIB,ON COUMADIN AFTER STROKE IN\n R PUPIL LARGER THAN LEFT,L ARM HAS DECREASED RANGE OF MOTION DUE TO\n FALL ON ICE IN WEAKER,ANGIOPLASTY 10 YRS AGO .HAS RENAL\n INSUFFICENCY .DESPITE DIURESIS PT REMAINS HYPOXIC TO CCU FOR FURTHER\n TX,CHF /? PNA\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Rhonchi\n up bilateral LS, room air o2 sats 80%, temp 102, pt forgetful\n at times, afib r 37-70, urine output decreasing\n Action:\n 5l nc when resting nonrebreather with exertion, antihypertensives,\n antibiotics, bc x2 obtained, pt reoriented to place, on heparin gtt\n Response:\n Maintaining 02 sats >93%, pt appears more relaxed and calm, pt remains\n on bed rest, trop up to .19 from .11 ck down to 64 from 76 lactate 1.07\n Plan:\n ? PNA, UTI, pt to get antibiotics this am, bed rest, to commode with 2\n people assist pt very weak when standing must wait and watch pt if on\n commode pt will try to get up to walk to bathroom, get sputum sample if\n possible, follow temp and give Tylenol for comfort, monitor mental\n status on heparin gtt , monitor I&O\n" }, { "category": "Physician ", "chartdate": "2115-08-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 481310, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n FEVER - 102.0\nF - 08:00 PM -> blood cultures sent\n asymptomatic sinus bradycardia into 40s while sleeping\n History obtained from Patient\n Allergies:\n History obtained from PatientAce Inhibitors\n Renal Toxicity;\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, chills\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: No(t) Cough, shortness of breath improved greatly\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37\nC (98.6\n HR: 46 (43 - 73) bpm\n BP: 135/39(63) {114/38(60) - 179/67(95)} mmHg\n RR: 17 (15 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 329 mL\n 416 mL\n PO:\n 240 mL\n 340 mL\n TF:\n IVF:\n 89 mL\n 76 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 740 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -411 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: Systolic), II/VI holosystolic at RUSB and\n apex\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, Wheezes : occl exp wheeze on left)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, mid-leg bilat, chronic venous stasis changes\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 232 K/uL\n 10.0 g/dL\n 106 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 47 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 7.7 K/uL\n [image002.jpg]\n 12:05 AM\n 05:43 AM\n WBC\n 7.7\n Hct\n 31.8\n Plt\n 232\n Cr\n 1.6\n TropT\n 0.19\n 0.15\n Glucose\n 106\n Other labs: PT / PTT / INR:25.5/123.4/2.5, CK / CKMB /\n Troponin-T:70//0.15, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n ASSESSMENT AND PLAN: 82yo M with h/o CAD s/p PCTA 15 years ago,\n diastolic CHF with h/o fluid overload on lasix, afib on coumadin with\n recent admission for retinal occlusion while on warfarin, now admitted\n with DOE, hypoxia, and fever.\n .\n # Hypoxia: Likely this is multifactorial. He has evidence of volume\n overload on exam, on CXR, and with his elevated BNP. In addition he has\n had fever and a questionable infiltrate on his CXR although he denies\n productive cough and sick contacts he could have PNA. PE is less likely\n since he is systemically anti-coagulated and he has other more likely\n etiologies for his hypoxia ( score 4). However, his INR was\n subtherapeutic on admission so this remains a possibility. Currently\n favor community-acquired PNA superimposed on mild diastolic CHF.\n - Will continue treatment for community acquired pneumonia with\n azithromycin and cetriaxone given the fever, hypoxia and possible\n infiltrates on CXR.\n - TTE showed new LV dilation likely causing more severe MR with\n preserved LVEF (although this is likely over-estimated in MR)\n consistent with acute exacerbation of his diastolic CHF. Will treat\n symptomatically with lasix with goal I/O of negative 1-2L today.\n - Will cycle cardiac enzymes to rule out acute coronary event although\n more likely the slight elevation is from stretch from fluid overload\n rather than ACS.\n - Daily I/O, weights\n - Low salt diet\n - Patient is unable to tolerate ACE-I or beta blockers ADRs in\n past. Will continue on current blood pressure regimen for afterload\n reduction with felodipine and hydralazine and continue statin and ASA\n - Non-invasive ventilation as needed to keep O2 sats >90%\n - LENIs today to r/o DVT as if he has a DVT while on coumadin he has\n technically failed anti-coagulation and may need IVC filter to avoid\n PEs.\n - Will hold off on CTA for PE as more likely diagnoses at this time and\n score < 4.\n - CXR today to evaluate for blossoming of the PNA and lessening of\n pulmonary edema with diuresis\n .\n # Fever: Most likely infectious with either pulmonary or urinary\n infection being most probable given leukocytosis, positive UA and\n hypoxia with CXR showing possible infiltrate.\n - Blood and urine cultures pending\n - attempt to obtain sputum culture\n - Continue to treat for CAP with CTX and azithromycin. be able to\n change to an oral regimen if stabilizes over next few days and cultures\n do not grow resistent organisms.\n - Will treat for UTI with ceftriaxone.\n - Follow up cultures and narrow antibiotics as able.\n .\n # CORONARIES: Patient has remote history of CAD s/p PTCA at OSH and\n currently has slightly elevated troponins with flat CKs and negative\n MBs in the setting of CRF. currently denies anginal symptoms although\n his SOB could be an anginal equivalent and it is possible that 3 days\n ago he had an acute event causing the acute exacerbation of his CHF.\n More likely, however, is that because of his infection he developed\n fluid overload and ventricular dilation causing troponin elevation that\n was not cleared his renal failure.\n - Will cycle cardiac enzymes.\n - ECG this morning\n - Continue asa, statin at home dose. Unable to tolerate beta blockers\n and ace inhibitors.\n .\n # PUMP: Patient has history of diastolic dysfunction and has had\n episodes of fluid overload treated with oral lasix in the past. TTE\n today revealed new LV dilation and likely as a result worsening of his\n MR . Unclear etiology of his new LV dilation although\n potentially infection vs late presentation of ACS.\n - Will treat acute exacerbation of diastolic CHF as above with lasix,\n daily weights, I/O, salt restricted diet and home medications\n - Goal I/O 2L over 24 hours\n .\n # RHYTHM: currently in slow afib with some EKGs looking like wandering\n pacemaker and rate controlled in 50s. CHADS2 score 5.\n - Will continue calcium channel blocker as ADR with beta blocker\n - EKG this morning\n - heparin gtt given sub-therapeutic INR on admission and recent retinal\n artery occlusion (thought more likely to be plaque not embolic from\n heart per notes but no documentation from OSH where diagnosed so\n unclear and thus higher risk patient than average AFib)\n - continue coumadin 5mg for now as starting on abx and likely to\n increase coumadin level so no need for increasing his home dose now.\n - check daily INRs\n .\n # Hypertension: Patient's BP was 170/70 at recent PCP visit and has\n been dificult to control according to OMR notes for last several years.\n Unable to tolerate ACE inhibitors or beta blockers\n - Will continue hydral/Imdur for afterload reduction\n - Will continue CCB\n - Will continue clonidine given rebound effect with daily dosing\n - nitro gtt if hypertensive and acutely sob although on floor patient\n reportedly had precipitous drop in BP when this was attempted.\n .\n # Chronic renal insufficiency: Currently patient is below his baseline\n creatinine of 1.7.\n - Will continue home regimen and follow creatinines daily\n .\n # Hyperlipidemia: As above will continue home dose of statin.\n .\n # Gout: Will continue home dose of allopurinol\n FEN: No IVF, E- replete PRN, N- hh/low salt\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with coumadin and hep gtt until inr therapeutic\n -Pain management with apap\n -Bowel regimen with colace, senna\n CODE: DNR/DNI confirmed on admission with patient and family\n CONTACT: Wife ; Son \n O: CCU pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2115-08-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 481319, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n FEVER - 102.0\nF - 08:00 PM -> blood cultures sent\n asymptomatic sinus bradycardia into 40s while sleeping\n History obtained from Patient\n Allergies:\n History obtained from PatientAce Inhibitors\n Renal Toxicity;\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, chills\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: No(t) Cough, shortness of breath improved greatly\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37\nC (98.6\n HR: 46 (43 - 73) bpm\n BP: 135/39(63) {114/38(60) - 179/67(95)} mmHg\n RR: 17 (15 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 329 mL\n 416 mL\n PO:\n 240 mL\n 340 mL\n TF:\n IVF:\n 89 mL\n 76 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 740 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -411 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: Systolic), II/VI holosystolic at RUSB and\n apex\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, Wheezes : occl exp wheeze on left)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, mid-leg bilat, chronic venous stasis changes\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 232 K/uL\n 10.0 g/dL\n 106 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 47 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 7.7 K/uL\n [image002.jpg]\n 12:05 AM\n 05:43 AM\n WBC\n 7.7\n Hct\n 31.8\n Plt\n 232\n Cr\n 1.6\n TropT\n 0.19\n 0.15\n Glucose\n 106\n Other labs: PT / PTT / INR:25.5/123.4/2.5, CK / CKMB /\n Troponin-T:70//0.15, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n ASSESSMENT AND PLAN: 82yo M with h/o CAD s/p PCTA 15 years ago,\n diastolic CHF with h/o fluid overload on lasix, afib on coumadin with\n recent admission for retinal occlusion while on warfarin, now admitted\n with DOE, hypoxia, and fever.\n .\n # Hypoxia: Likely this is multifactorial. He has evidence of volume\n overload on exam, on CXR, and with his elevated BNP. In addition he has\n had fever and a questionable infiltrate on his CXR although he denies\n productive cough and sick contacts he could have PNA. PE is less likely\n since he is systemically anti-coagulated and he has other more likely\n etiologies for his hypoxia ( score 4). However, his INR was\n subtherapeutic on admission so this remains a possibility. Currently\n favor community-acquired PNA superimposed on mild diastolic CHF.\n - Will continue treatment for community acquired pneumonia with\n azithromycin and cetriaxone given the fever, hypoxia and possible\n infiltrates on CXR.\n - TTE showed new LV dilation likely causing more severe MR with\n preserved LVEF (although this is likely over-estimated in MR)\n consistent with acute exacerbation of his diastolic CHF. Will treat\n symptomatically with lasix with goal I/O of negative 1-2L today.\n - Will cycle cardiac enzymes to rule out acute coronary event although\n more likely the slight elevation is from stretch from fluid overload\n rather than ACS.\n - Daily I/O, weights\n - Low salt diet\n - Patient is unable to tolerate ACE-I or beta blockers ADRs in\n past. Will continue on current blood pressure regimen for afterload\n reduction with felodipine and hydralazine and continue statin and ASA\n - Non-invasive ventilation as needed to keep O2 sats >90%\n - LENIs today to r/o DVT as if he has a DVT while on coumadin he has\n technically failed anti-coagulation and may need IVC filter to avoid\n PEs.\n - Will hold off on CTA for PE as more likely diagnoses at this time and\n score < 4.\n - CXR today to evaluate for blossoming of the PNA and lessening of\n pulmonary edema with diuresis -> evidence of LLL vs LUL infiltrate on\n AP portable today\n .\n # Fever: Most likely infectious with either pulmonary or urinary\n infection being most probable given leukocytosis, positive UA and\n hypoxia with CXR showing possible infiltrate.\n - Blood and urine cultures pending\n - attempt to obtain sputum culture\n - Continue to treat for CAP with CTX and azithromycin. be able to\n change to an oral regimen if stabilizes over next few days and cultures\n do not grow resistent organisms.\n - Will treat for UTI with ceftriaxone.\n - Follow up cultures and narrow antibiotics as able.\n .\n # CORONARIES: Patient has remote history of CAD s/p PTCA at OSH and\n currently has slightly elevated troponins with flat CKs and negative\n MBs in the setting of CRF. currently denies anginal symptoms although\n his SOB could be an anginal equivalent and it is possible that 3 days\n ago he had an acute event causing the acute exacerbation of his CHF.\n More likely, however, is that because of his infection he developed\n fluid overload and ventricular dilation causing troponin elevation that\n was not cleared his renal failure.\n - Will cycle cardiac enzymes.\n - ECG this morning\n - Continue asa, statin at home dose. Unable to tolerate beta blockers\n and ace inhibitors.\n .\n # PUMP: Patient has history of diastolic dysfunction and has had\n episodes of fluid overload treated with oral lasix in the past. TTE\n today revealed new LV dilation and likely as a result worsening of his\n MR . Unclear etiology of his new LV dilation although\n potentially infection vs late presentation of ACS.\n - Will treat acute exacerbation of diastolic CHF as above with lasix,\n daily weights, I/O, salt restricted diet and home medications\n - Goal I/O 2L over 24 hours\n .\n # RHYTHM: currently in slow afib with some EKGs looking like wandering\n pacemaker and rate controlled in 50s. CHADS2 score 5. Pt has\n asymptomatic bradycardia, with evidence of AV delay and Wenkebach on\n ECGs.\n - Will continue calcium channel blocker as ADR with beta blocker\n - EKG this morning\n - heparin gtt given sub-therapeutic INR on admission and recent retinal\n artery occlusion (thought more likely to be plaque not embolic from\n heart per notes but no documentation from OSH where diagnosed so\n unclear and thus higher risk patient than average AFib)\n - continue coumadin 5mg for now as starting on abx and likely to\n increase coumadin level so no need for increasing his home dose now.\n - check daily INRs\n .\n # Hypertension: Patient's BP was 170/70 at recent PCP visit and has\n been dificult to control according to OMR notes for last several years.\n Unable to tolerate ACE inhibitors or beta blockers\n - Will continue hydral/Imdur for afterload reduction\n - Will continue CCB\n - Will continue clonidine given rebound effect with daily dosing\n - nitro gtt if hypertensive and acutely sob although on floor patient\n reportedly had precipitous drop in BP when this was attempted.\n .\n # Chronic renal insufficiency: Currently patient is below his baseline\n creatinine of 1.7.\n - Will continue home regimen and follow creatinines daily\n .\n # Hyperlipidemia: As above will continue home dose of statin.\n .\n # Gout: Will continue home dose of allopurinol\n FEN: No IVF, E- replete PRN, N- hh/low salt\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with coumadin and hep gtt until inr therapeutic\n -Pain management with apap\n -Bowel regimen with colace, senna\n CODE: DNR/DNI confirmed on admission with patient and family\n CONTACT: Wife ; Son \n O: CCU pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2115-08-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 481322, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n FEVER - 102.0\nF - 08:00 PM -> blood cultures sent\n asymptomatic sinus bradycardia into 40s while sleeping\n History obtained from Patient\n Allergies:\n History obtained from PatientAce Inhibitors\n Renal Toxicity;\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, chills\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: No(t) Cough, shortness of breath improved greatly\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37\nC (98.6\n HR: 46 (43 - 73) bpm\n BP: 135/39(63) {114/38(60) - 179/67(95)} mmHg\n RR: 17 (15 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 329 mL\n 416 mL\n PO:\n 240 mL\n 340 mL\n TF:\n IVF:\n 89 mL\n 76 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 740 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -411 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: Systolic), II/VI holosystolic at RUSB and\n apex\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, Wheezes : occl exp wheeze on left)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, mid-leg bilat, chronic venous stasis changes\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 232 K/uL\n 10.0 g/dL\n 106 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 47 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 7.7 K/uL\n [image002.jpg]\n 12:05 AM\n 05:43 AM\n WBC\n 7.7\n Hct\n 31.8\n Plt\n 232\n Cr\n 1.6\n TropT\n 0.19\n 0.15\n Glucose\n 106\n Other labs: PT / PTT / INR:25.5/123.4/2.5, CK / CKMB /\n Troponin-T:70//0.15, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n ASSESSMENT AND PLAN: 82yo M with h/o CAD s/p PCTA 15 years ago,\n diastolic CHF with h/o fluid overload on lasix, afib on coumadin with\n recent admission for retinal occlusion while on warfarin, now admitted\n with DOE, hypoxia, and fever.\n .\n # Hypoxia: Likely this is multifactorial. He has evidence of volume\n overload on exam, on CXR, and with his elevated BNP. In addition he has\n had fever and a questionable infiltrate on his CXR although he denies\n productive cough and sick contacts he could have PNA. PE is less likely\n since he is systemically anti-coagulated and he has other more likely\n etiologies for his hypoxia ( score 4). However, his INR was\n subtherapeutic on admission so this remains a possibility. Currently\n favor community-acquired PNA superimposed on mild diastolic CHF.\n - Will continue treatment for community acquired pneumonia with\n azithromycin and cetriaxone given the fever, hypoxia and possible\n infiltrates on CXR.\n - TTE showed new LV dilation likely causing more severe MR with\n preserved LVEF (although this is likely over-estimated in MR)\n consistent with acute exacerbation of his diastolic CHF. Will treat\n symptomatically with lasix with goal I/O of negative 1-2L today.\n - Will cycle cardiac enzymes to rule out acute coronary event although\n more likely the slight elevation is from stretch from fluid overload\n rather than ACS.\n - Daily I/O, weights\n - Low salt diet\n - Patient is unable to tolerate ACE-I or beta blockers ADRs in\n past. Will continue on current blood pressure regimen for afterload\n reduction with felodipine and hydralazine and continue statin and ASA\n - Non-invasive ventilation as needed to keep O2 sats >90%\n - LENIs today to r/o DVT as if he has a DVT while on coumadin he has\n technically failed anti-coagulation and may need IVC filter to avoid\n PEs.\n - Will hold off on CTA for PE as more likely diagnoses at this time and\n score < 4.\n - CXR today to evaluate for blossoming of the PNA and lessening of\n pulmonary edema with diuresis -> evidence of LLL vs LUL infiltrate on\n AP portable today\n .\n # Fever: Most likely infectious with either pulmonary or urinary\n infection being most probable given leukocytosis, positive UA and\n hypoxia with CXR showing possible infiltrate.\n - Blood and urine cultures pending\n - attempt to obtain sputum culture\n - Continue to treat for CAP with CTX and azithromycin. be able to\n change to an oral regimen if stabilizes over next few days and cultures\n do not grow resistent organisms.\n - Will treat for UTI with ceftriaxone.\n - Follow up cultures and narrow antibiotics as able.\n .\n # CORONARIES: Patient has remote history of CAD s/p PTCA at OSH and\n currently has slightly elevated troponins with flat CKs and negative\n MBs in the setting of CRF. currently denies anginal symptoms although\n his SOB could be an anginal equivalent and it is possible that 3 days\n ago he had an acute event causing the acute exacerbation of his CHF.\n More likely, however, is that because of his infection he developed\n fluid overload and ventricular dilation causing troponin elevation that\n was not cleared his renal failure.\n - Will cycle cardiac enzymes.\n - ECG this morning\n - Continue asa, statin at home dose. Unable to tolerate beta blockers\n and ace inhibitors.\n .\n # PUMP: Patient has history of diastolic dysfunction and has had\n episodes of fluid overload treated with oral lasix in the past. TTE\n today revealed new LV dilation and likely as a result worsening of his\n MR . Unclear etiology of his new LV dilation although\n potentially infection vs late presentation of ACS.\n - Will treat acute exacerbation of diastolic CHF as above with lasix,\n daily weights, I/O, salt restricted diet and home medications\n - Goal I/O 2L over 24 hours\n .\n # RHYTHM: currently in slow afib with some EKGs looking like wandering\n pacemaker and rate controlled in 50s. CHADS2 score 5. Pt has\n asymptomatic bradycardia, with evidence of AV delay and Wenkebach on\n ECGs.\n - Will continue calcium channel blocker as ADR with beta blocker\n - EKG this morning\n - heparin gtt given sub-therapeutic INR on admission and recent retinal\n artery occlusion (thought more likely to be plaque not embolic from\n heart per notes but no documentation from OSH where diagnosed so\n unclear and thus higher risk patient than average AFib)\n - continue coumadin 5mg for now as starting on abx and likely to\n increase coumadin level so no need for increasing his home dose now.\n - check daily INRs\n .\n # Hypertension: Patient's BP was 170/70 at recent PCP visit and has\n been dificult to control according to OMR notes for last several years.\n Unable to tolerate ACE inhibitors or beta blockers\n - Will continue hydral/Imdur for afterload reduction\n - Will continue CCB\n - Will continue clonidine given rebound effect with daily dosing\n - nitro gtt if hypertensive and acutely sob although on floor patient\n reportedly had precipitous drop in BP when this was attempted.\n .\n # Chronic renal insufficiency: Currently patient is below his baseline\n creatinine of 1.7.\n - Will continue home regimen and follow creatinines daily\n .\n # Hyperlipidemia: As above will continue home dose of statin.\n .\n # Gout: Will continue home dose of allopurinol\n FEN: No IVF, E- replete PRN, N- hh/low salt\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with coumadin and hep gtt until inr therapeutic\n -Pain management with apap\n -Bowel regimen with colace, senna\n CODE: DNR/DNI confirmed on admission with patient and family\n CONTACT: Wife ; Son \n O: CCU pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2115-08-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 481324, "text": "Chief Complaint: dyspnea\n 24 Hour Events:\n FEVER - 102.0\nF - 08:00 PM -> blood cultures sent\n asymptomatic sinus bradycardia into 40s while sleeping\n History obtained from Patient\n Allergies:\n History obtained from PatientAce Inhibitors\n Renal Toxicity;\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, chills\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: No(t) Cough, shortness of breath improved greatly\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37\nC (98.6\n HR: 46 (43 - 73) bpm\n BP: 135/39(63) {114/38(60) - 179/67(95)} mmHg\n RR: 17 (15 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 329 mL\n 416 mL\n PO:\n 240 mL\n 340 mL\n TF:\n IVF:\n 89 mL\n 76 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 740 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -411 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: Systolic), II/VI holosystolic at RUSB and\n apex\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bibasilar, Wheezes : occl exp wheeze on left)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, mid-leg bilat, chronic venous stasis changes\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 232 K/uL\n 10.0 g/dL\n 106 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 47 mg/dL\n 104 mEq/L\n 143 mEq/L\n 31.8 %\n 7.7 K/uL\n [image002.jpg]\n 12:05 AM\n 05:43 AM\n WBC\n 7.7\n Hct\n 31.8\n Plt\n 232\n Cr\n 1.6\n TropT\n 0.19\n 0.15\n Glucose\n 106\n Other labs: PT / PTT / INR:25.5/123.4/2.5, CK / CKMB /\n Troponin-T:70//0.15, Ca++:8.8 mg/dL, Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n ASSESSMENT AND PLAN: 82yo M with h/o CAD s/p PCTA 15 years ago,\n diastolic CHF with h/o fluid overload on lasix, afib on coumadin with\n recent admission for retinal occlusion while on warfarin, now admitted\n with DOE, hypoxia, and fever.\n .\n # Hypoxia: Likely this is multifactorial. He has evidence of volume\n overload on exam, on CXR, and with his elevated BNP. In addition he has\n had fever and a questionable infiltrate on his CXR although he denies\n productive cough and sick contacts he could have PNA. PE is less likely\n since he is systemically anti-coagulated and he has other more likely\n etiologies for his hypoxia ( score 4). However, his INR was\n subtherapeutic on admission so this remains a possibility. Currently\n favor community-acquired PNA superimposed on mild diastolic CHF.\n - Will continue treatment for community acquired pneumonia with\n azithromycin and cetriaxone given the fever, hypoxia and possible\n infiltrates on CXR.\n - TTE showed new LV dilation likely causing more severe MR with\n preserved LVEF (although this is likely over-estimated in MR)\n consistent with acute exacerbation of his diastolic CHF. Will treat\n symptomatically with lasix with goal I/O of negative 1-2L today.\n - Will cycle cardiac enzymes to rule out acute coronary event although\n more likely the slight elevation is from stretch from fluid overload\n rather than ACS.\n - Daily I/O, weights\n - Low salt diet\n - Patient is unable to tolerate ACE-I or beta blockers ADRs in\n past. Will continue on current blood pressure regimen for afterload\n reduction with felodipine and hydralazine and continue statin and ASA\n - Non-invasive ventilation as needed to keep O2 sats >90%\n - LENIs today to r/o DVT as if he has a DVT while on coumadin he has\n technically failed anti-coagulation and may need IVC filter to avoid\n PEs.\n - Will hold off on CTA for PE as more likely diagnoses at this time and\n score < 4.\n - CXR today to evaluate for blossoming of the PNA and lessening of\n pulmonary edema with diuresis -> evidence of LLL vs LUL infiltrate on\n AP portable today\n .\n # Fever: Most likely infectious with either pulmonary or urinary\n infection being most probable given leukocytosis, positive UA and\n hypoxia with CXR showing possible infiltrate.\n - Blood and urine cultures pending\n - attempt to obtain sputum culture\n - Continue to treat for CAP with CTX and azithromycin. be able to\n change to an oral regimen if stabilizes over next few days and cultures\n do not grow resistent organisms.\n - Will treat for UTI with ceftriaxone.\n - Follow up cultures and narrow antibiotics as able.\n .\n # CORONARIES: Patient has remote history of CAD s/p PTCA at OSH and\n currently has slightly elevated troponins with flat CKs and negative\n MBs in the setting of CRF. currently denies anginal symptoms although\n his SOB could be an anginal equivalent and it is possible that 3 days\n ago he had an acute event causing the acute exacerbation of his CHF.\n More likely, however, is that because of his infection he developed\n fluid overload and ventricular dilation causing troponin elevation that\n was not cleared his renal failure.\n - Will cycle cardiac enzymes.\n - ECG this morning\n - Continue asa, statin at home dose. Unable to tolerate beta blockers\n and ace inhibitors.\n .\n # PUMP: Patient has history of diastolic dysfunction and has had\n episodes of fluid overload treated with oral lasix in the past. TTE\n today revealed new LV dilation and likely as a result worsening of his\n MR . Unclear etiology of his new LV dilation although\n potentially infection vs late presentation of ACS.\n - Will treat acute exacerbation of diastolic CHF as above with lasix,\n daily weights, I/O, salt restricted diet and home medications\n - Goal I/O 2L over 24 hours\n .\n # RHYTHM: currently in slow afib with some EKGs looking like wandering\n pacemaker and rate controlled in 50s. CHADS2 score 5. Pt has\n asymptomatic bradycardia, with evidence of AV delay and Wenkebach on\n ECGs.\n - Will continue calcium channel blocker as ADR with beta blocker\n - EKG this morning\n - heparin gtt given sub-therapeutic INR on admission and recent retinal\n artery occlusion (thought more likely to be plaque not embolic from\n heart per notes but no documentation from OSH where diagnosed so\n unclear and thus higher risk patient than average AFib)\n - continue coumadin 5mg for now as starting on abx and likely to\n increase coumadin level so no need for increasing his home dose now.\n - check daily INRs\n .\n # Hypertension: Patient's BP was 170/70 at recent PCP visit and has\n been dificult to control according to OMR notes for last several years.\n Unable to tolerate ACE inhibitors or beta blockers\n - Will continue hydral/Imdur for afterload reduction\n - Will continue CCB\n - Will continue clonidine given rebound effect with daily dosing\n - nitro gtt if hypertensive and acutely sob although on floor patient\n reportedly had precipitous drop in BP when this was attempted.\n .\n # Chronic renal insufficiency: Currently patient is below his baseline\n creatinine of 1.7.\n - Will continue home regimen and follow creatinines daily\n .\n # Hyperlipidemia: As above will continue home dose of statin.\n .\n # Gout: Will continue home dose of allopurinol\n FEN: No IVF, E- replete PRN, N- hh/low salt\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with coumadin and hep gtt until inr therapeutic\n -Pain management with apap\n -Bowel regimen with colace, senna\n CODE: DNR/DNI confirmed on admission with patient and family\n CONTACT: Wife ; Son \n O: CCU pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 70 minutes.\n ------ Protected Section Addendum Entered By: ,MD\n on: 09:48 ------\n" }, { "category": "Nursing", "chartdate": "2115-08-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 481224, "text": "Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2115-08-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 481227, "text": "82 YR OLD C H/O CHF CAME TO ED C SEVERAL DAY OF SOB . 80 MG LASIX\n GIVEN X2 ,DIURESED 2.5 L .WEANED FROM NON REBREATHER TO 6L NP .ALSO\n GIVEN CEFTRIAXONE,AZITHROMYCIN .PT ,STARTED ON LOW DOSE\n NITRO BUT BP COULD NOT TOLERATE IT .HX AFIB,ON COUMADIN AFTER STROKE IN\n R PUPIL LARGER THAN LEFT,L ARM HAS DECREASED RANGE OF MOTION DUE TO\n FALL ON ICE IN WEAKER,ANGIOPLASTY 10 YRS AGO .HAS RENAL\n INSUFFICENCY .DESPITE DIURESIS PT REMAINS HYPOXIC TO CCU FOR FURTHER\n TX,CHF /? PNA\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Rhonchi\n up bilateral LS, room air o2 sats 80%, temp 102\n Action:\n 5l nc when resting nonrebreather with exertion, antihypertensives,\n antibiotics, bc x2 obtained\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2115-08-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 481291, "text": "82 YR OLD C H/O CHF CAME TO ED C SEVERAL DAY OF SOB . 80 MG LASIX\n GIVEN X2 ,DIURESED 2.5 L .WEANED FROM NON REBREATHER TO 6L NP .ALSO\n GIVEN CEFTRIAXONE,AZITHROMYCIN .PT ,STARTED ON LOW DOSE\n NITRO BUT BP COULD NOT TOLERATE IT .HX AFIB,ON COUMADIN AFTER STROKE IN\n R PUPIL LARGER THAN LEFT,L ARM HAS DECREASED RANGE OF MOTION DUE TO\n FALL ON ICE IN WEAKER,ANGIOPLASTY 10 YRS AGO .HAS RENAL\n INSUFFICENCY .DESPITE DIURESIS PT REMAINS HYPOXIC TO CCU FOR FURTHER\n TX,CHF /? PNA\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Rhonchi\n up bilateral LS, room air o2 sats 80%, temp 102, pt forgetful\n at times, afib r 37-70, urine output decreasing , pt forgetful\n Action:\n 5l nc when resting nonrebreather with exertion, antihypertensives,\n antibiotics, bc x2 obtained, pt reoriented to place, on heparin gtt, pt\n reoriented\n Response:\n Maintaining 02 sats >93%, pt appears more relaxed and calm, pt remains\n on bed rest, trop up to .19 from .11 ck down to 64 from 76 lactate 1.07\n , pt calm\n Plan:\n ? PNA, UTI, pt to get antibiotics this am, bed rest, to commode with 2\n people assist pt very weak when standing must wait and watch pt if on\n commode pt will try to get up to walk to bathroom, get sputum sample if\n possible, follow temp and give Tylenol for comfort, monitor mental\n status on heparin gtt , monitor I&O\n" }, { "category": "Radiology", "chartdate": "2115-08-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1095883, "text": " 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for evidence of volume overload or infection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for evidence of volume overload or infection\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: An 82-year-old male with shortness of breath.\n\n COMPARISON: Chest radiograph from .\n\n SINGLE FRONTAL VIEW OF THE CHEST: Bilateral perihilar opacities are noted.\n There is a tiny right pleural effusion. No pneumothorax is seen. The heart\n is mildly enlarged. The aorta is calcified and tortuous. Degenerative\n changes of the spine are noted.\n\n IMPRESSION:\n\n Bilateral perihilar opacities may represent congestive heart failure versus\n pneumonia. In the setting of the patient's elevated BNP, findings more likely\n represent moderate congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2115-08-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1096085, "text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?chf vs pna\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with hypoxia and h/o CHF with low grade fevers and cough\n REASON FOR THIS EXAMINATION:\n ?chf vs pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF with low-grade fevers and cough.\n\n FINDINGS: In comparison with the study of , there is little overall change\n in the bilateral lower lung and left perihilar patchy opacifications,\n consistent with multifocal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-08-21 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1096088, "text": " 8:01 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: BILATERAL LEG EDEMA\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with R>L LE edema & hypoxemia\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MRSg WED 10:01 AM\n No DVT in either leg. Right cyst.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old man with lower extremity edema and hypoxemia.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler son of bilateral common femoral,\n superficial femoral, popliteal and tibial veins were performed. There is\n normal flow, compression and augmentation seen in all of the vessels.\n\n Transverse and sagittal images of the right popliteal fossa demonstrate a\n complex avascular fluid collection which measures 5.9 x 1.6 x 2.4 cm. This\n collection is consistent with cyst.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg. cyst\n seen in the right popliteal fossa.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-08-21 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1096089, "text": ", H. 8:01 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: BILATERAL LEG EDEMA\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with R>L LE edema & hypoxemia\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n No DVT in either leg. Right cyst.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-08-20 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1095965, "text": " 2:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for worsening pulm edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with CHF, acute hypoxemia\n REASON FOR THIS EXAMINATION:\n eval for worsening pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CHEST PORTABLE AP\n\n REASON FOR EXAM: Worsening pulmonary edema.\n\n FINDINGS: Since the previous study, the appearances have remained unchanged\n with bilateral perihilar airspace opacities, worse on the left side than the\n right side. No new consolidation or pneumothorax. Mild cardiomegaly is\n unchanged.\n\n IMPRESSION:\n\n Stable appearance with bilateral perihilar airspace opacities. Mild\n cardiomegaly.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2142-10-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1207753, "text": " 4:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?eval for interval change\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with s/p intubation w/ worsening respiratory status\n REASON FOR THIS EXAMINATION:\n ?eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH \n\n COMPARISON: \n\n FINDINGS: Worsening bibasilar airspace opacities, concerning for pneumonia.\n Given the distribution, this could reflect an aspiration pneumonia. Otherwise\n no substantial change since recent radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1207491, "text": " 5:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f pneumonia\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man s/p MCC c/b aspiration\n REASON FOR THIS EXAMINATION:\n e/f pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old male status post motorcycle collision and with\n aspiration. Interval evaluation of the chest.\n\n TECHNIQUE: Single frontal portable radiograph of the chest.\n\n COMPARISON: Radiographs dated and correlation with CT\n dated .\n\n FINDINGS: No new focal opacity to suggest pneumonia is seen. Prior opacity\n at the right base is improved. No pleural effusion, pulmonary edema, or\n pneumothorax is present. The cardiomediastinal silhouette is normal. An\n endotracheal tube is in standard position with tip approximately 6 cm above\n the carina. An esophageal catheter courses inferior to the diaphragm with tip\n out of view of the radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-04 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1207367, "text": " 2:05 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: r/o injury\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL ADDENDUM\n No other fracture or malalignment is visualized in the osseous structures.\n This was discussed with KC at 5:50pm, by phone.\n\n \n\n\n 2:05 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: r/o injury\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30M s/p MCC found unresponsive\n REASON FOR THIS EXAMINATION:\n r/o injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:32 PM\n right upper lobe pulmonary contusion; multifocal areas of probable aspiration;\n bilateral rib fractures (2nd and 3rd on the left, 5th on the right); small\n amount of mildly complex free fluid in the pelvis\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motorcycle crash, found unresponsive.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired contiguous axial images from the lung apices to the\n pubic symphysis were acquired following the administration of 130 cc of IV\n Optiray. Coronal and sagittal reconstructions were performed.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: No acute aortic injury is\n identified. There is no mediastinal hematoma. An endotracheal tube\n terminates in standard position below the thoracic inlet. No hilar,\n mediastinal, or axillary lymphadenopathy is present. Heart, great vessels,\n and pericardium are within normal limits. No pericardial or pleural effusion\n is present.\n\n Lung window images demonstrate a subpleural bleb within the right lung apex,\n but no pneumothorax. Hazy ground-glass opacity along the periphery of the\n right upper lobe anteriorly most likely represents contusion. Nodular\n ill-defined opacities within the right upper lobe, right middle lobe, right\n lower lobe, and left lower lobe, with a more focal consolidative opacity in\n the anterior aspect of the right lower lobe are all likely representative of\n aspiration. There is mild bronchial wall thickening with secretions noted in\n the right lower lobe bronchi.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The nasogastric tube tip\n terminates within the stomach. The liver, gallbladder, pancreas, spleen,\n adrenal glands, both kidneys, ureters, stomach, and loops of large and small\n bowel are all within normal limits. The abdominal aorta is normal in caliber\n throughout. There is no free air or free fluid. No pathologically enlarged\n mesenteric or retroperitoneal lymph nodes are seen.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Evaluation is slightly limited\n due to motion artifact. Small amount of mildly complex free fluid is noted\n within the pelvis. A Foley catheter is noted within the bladder, which\n (Over)\n\n 2:05 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: r/o injury\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n contains a small amount of intraluminal air. The remainder of the bladder is\n unremarkable. The pelvic loops of bowel, distal ureters, rectum are within\n normal limits.\n\n BONE WINDOWS: Fractures of the left anterior second and third ribs, and right\n lateral fifth ribs are noted.\n\n IMPRESSION:\n 1. Pulmonary contusion within the right upper lobe.\n 2. Multifocal areas of aspiration within the right lung and left lower lobe.\n\n 3. Small amount of minimally complex fluid within the pelvis, but no acute\n intra-abdominal or intrapelvic traumatic injury otherwise identified.\n 4. Bilateral rib fractures as described above.\n \n\n" }, { "category": "Radiology", "chartdate": "2142-10-08 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1208036, "text": " 8:00 PM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: please evaluate for c-spine/cord injury\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with TBI and suspected and concern for c-spine injury\n REASON FOR THIS EXAMINATION:\n please evaluate for c-spine/cord injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man with traumatic brain injury and suspected .\n MRI cervical spine is requested to rule out cervical spine injury.\n\n COMPARISON: CT C-spine .\n\n TECHNIQUE: Sagittal T1, T2, STIR, and diffusion-weighted sequences were\n obtained. Axial T2 and gradient echo sequences were then obtained through the\n cervical spine.\n\n FINDINGS: Cervical vertebrae reveal normal height, signal intensity and\n alignment. Craniocervical junction appears normal. Cervical spinal cord\n reveals normal morphology and signal intensity. Pre- and paravertebral and\n posterior paraspinal soft tissues appear unremarkable. Fluid signal is seen\n within the oropharynx and around the endotracheal tube, likely secondary to\n intubation.\n\n There is no spinal canal or neural foraminal narrowing seen. Intervertebral\n discs are normal in height and signal intensities. There is no evidence of\n ligamentous injuries.\n\n IMPRESSION: Unremarkable MRI of the cervical spine.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207365, "text": " 2:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30M s/p MCC found unresponsive\n REASON FOR THIS EXAMINATION:\n r/o injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:37 PM\n 1. + intraparenchymal hemorrhage in left frontal lobe, + focus of SAH at\n right frontovertex\n 2. + facial fractures with opacification of the right maxillary sinus and\n ethmoid air cells from hemorrhage\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old male status post motorcycle collision, here to assess\n for intra- and extracranial injuries.\n\n COMPARISON: No prior studies available.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images were obtained through the\n brain. Sagittal and coronal reformations were reviewed.\n\n FINDINGS: This study is technically limited due to motion artifact. There\n are multiple foci of intraparenchymal hemorrhage seen within the grey-white\n matter junction of the left frontal lobe and right frontal lobe towards the\n vertex, as well as the left basal ganglia and left internal capsule. A tiny\n focus of extra-axial hemorrhage adjacent to the right frontal intraparenchymal\n hemorrhage also is likely present suggestive of subarachnoid blood. Thin\n hyperdensity layering along the left tentorium may represent a tiny subdural\n hemorrhage. There is no evidence of edema, mass effect or shift of normally\n midline structures. The -white matter interface is well preserved with no\n evidence of acute major vascular territorial infarct. The ventricles and\n sulci are normal in size and configuration.\n\n The extracalvarial soft tissues show right frontal scalp and periorbital\n hematoma. Multiple facial fractures are identified of the right superior\n lateral orbital wall and inferolateral orbital wall. There is a fracture of\n the floor of the right orbit with a displaced fragment displaced in the right\n maxillary sinus without herniation of extraocular musculature. Opacification\n in the right maxillary sinus and right ethmoid air cells suggests hemorrhage\n from the multiple facial fractures. The skull base is intact without\n fracture. The bilateral globes are intact with lenses in place bilaterally.\n No retrobulbar hematoma present.\n\n IMPRESSION:\n 1. Multiple intraparenchymal hemorrhages compatible with diffuse axonal\n injury.\n 2. Tiny extra-axial hemorrhage noted adjacent to the right frontal\n intraparenchymal hemorrhage, likely subarachnoid blood. Small subdural\n (Over)\n\n 2:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o injury\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hemorrhage layering over the left tentorium.\n 3. Facial fractures as described above. A dedicated maxillofacial CT would\n be recommended when possible for further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-04 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1207366, "text": " 2:05 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30M s/p MCC found unresponsive\n REASON FOR THIS EXAMINATION:\n eval for injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:24 PM\n no fracture or subluxation\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motorcycle crash, found unresponsive.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired contiguous axial images of the cervical spine were\n obtained without intravenous contrast. Coronal and sagittal reconstructions\n were performed.\n\n CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: There is no fracture\n or subluxation. Vertebral body height and intervertebral disc spaces are\n maintained. No significant degenerative changes are present. Assessment of\n the prevertebral soft tissues is limited given the presence of an endotracheal\n tube and nasogastric tube. There are no paraspinal abnormalities visualized.\n Partially imaged is blood within the right maxillary sinus.\n\n IMPRESSION: No fracture or subluxation.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-08 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1208035, "text": " 7:58 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for intracranial process, diffuse axonal inj\n Admitting Diagnosis: BLUNT TRAUMA\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with TBI and suspected \n REASON FOR THIS EXAMINATION:\n please evaluate for intracranial process, diffuse axonal injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 32-year-old man with traumatic brain injury and suspected .\n\n COMPARISON: CT head of .\n\n TECHNIQUE: Sagittal T1, axial T1, T2, FLAIR, diffusion-weighted, and\n susceptibility sequences were obtained without contrast. Following\n intravenous administration of Magnevist, sagittal MP-RAGE and axial\n T1-weighted images were obtained. Axial and coronal reformats were generated\n and reviewed.\n\n FINDINGS: Again seen are multiple hemorrhagic contusions with surrounding\n edema in the right frontal, left basal ganglia, and left temporal regions.\n Multiple foci of abnormal susceptibility are seen at the -white matter\n junction in bilateral frontal lobes which are seen to bloom on the gradient\n echo sequences suggestive of microhemorrhages. There is no hydrocephalus or\n midline shift. There is no intraventricular extension of hemorrhage.\n Diffusion-weighted images reveal areas of slow diffusion within the left\n caudate head, distinct from the regions of hemorrhage, representing areas of\n ischemia. The ischemic changes are likely secondary to injury to the left\n lenticulostriate arteries. The visualized globes and mastoid air cells are\n unremarkable. Major intracranial flow voids appear normal. Abnormal signal\n intensity is seen within the right maxillary sinus, ethmoid and bilateral\n sphenoid sinuses. Correlating with the CT, multiple facial fractures are\n present with hemosinus.\n\n IMPRESSION:\n 1. Multiple hemorrhagic contusions in bilateral cerebral hemispheres as\n demonstrated on the previous CT. In addition, there are multiple tiny foci of\n microhemorrhages, predominantly at the -white matter junction in the\n frontal lobes consistent with diagnosis of diffuse axonal injury.\n 2. Areas of ischemia in the left caudate head likely from injury to the\n lenticulostriate branches. The A1 and M1 segments of the anterior and middle\n cerebral arteries respectively appear grossly normal. Please note that\n lenticulostriate arteries are much below the resolution of noninvasive imaging\n and cannot be reliably evaluated on CTA/MRA.\n\n Findings discussed by Dr. with on \n at 1:00 p.m.\n (Over)\n\n 7:58 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for intracranial process, diffuse axonal inj\n Admitting Diagnosis: BLUNT TRAUMA\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2142-10-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207496, "text": " 6:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: e/f progression of IPH, SDH, s/p bolt placement. Please do a\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man s/p MCC w/ IPH\n REASON FOR THIS EXAMINATION:\n e/f progression of IPH, SDH, s/p bolt placement. Please do at 6am.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc FRI 7:19 AM\n minimal interval change in bilateral parenchymal hemorrhage. Right facial\n fractures are noted involving the right orbital floor, superolateral corner of\n the right orbit, and right nasal bones. report available on listen line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motorcycle collision.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images were acquired through the head and facial bones\n without intravenous contrast. Coronal and sagittal reformatted images were\n also reviewed.\n\n FINDINGS: Right frontal parenchymal hemorrhage with a fluid-fluid level seen\n dependently is redemonstrated, unchanged in size. Foci of left frontal and\n temporal parenchymal hemorrhage are also redemonstrated, also appearing\n unchanged. There is no new intracranial hemorrhage, edema, mass effect, or\n vascular territorial infarction. Ventricles and sulci are unchanged in size\n and in configuration. An intracranial bolt is visualized, placed via a right\n frontal approach.\n\n Osseous structures are notable for a comminuted fracture involving the\n superolateral corner of the right orbit anteriorly with adjacent extraconal\n hematoma slightly impinging on the globe. Additionally, there is a comminuted\n right orbital floor fracture with a fallen osseous fragment, though no\n evidence of entrapment of the inferior rectus extraocular muscle. A minimally\n displaced fracture is also visualized in the right anterior maxillary sinus\n wall. There is expected near total opacification of the right maxillary\n sinus. The pterygoid plates, and zygomatic arches are intact. The lamina\n papyracea are intact. The nasal septum is intact, and notable for a\n moderate-sized rightward nasal septal spur. There is a minimally displaced\n right nasal bone fracture. Note is made of partial opacification of ethmoidal\n air cells bilaterally, greater on the right than left as well as moderate\n mucosal thickening in the left maxillary sinus, sphenoid sinus and frontal\n sinuses. The sphenoid sinus contains a single dominant septum which\n terminates near the midline.\n\n IMPRESSION:\n 1. Bilateral parenchymal hemorrhage as described above, similar to the most\n recent comparison study.\n 2. Right facial fractures as characterized above.\n (Over)\n\n 6:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: e/f progression of IPH, SDH, s/p bolt placement. Please do a\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2142-10-04 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1207360, "text": " 1:42 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motorcycle crash.\n\n COMPARISON: None.\n\n SUPINE AP VIEW OF THE CHEST: Overlying trauma board slightly limits\n evaluation. Endotracheal tube tip terminates 7 cm from the carina. The\n nasogastric tube tip is in the stomach. The cardiac, mediastinal and hilar\n contours are normal. Lungs are clear. No pneumothorax or large pleural\n effusion is present. No grossly displaced rib fractures are clearly\n visualized.\n\n IMPRESSION: Endotracheal tube and nasogastric tubes in standard positions. No\n acute traumatic injury seen in the thorax.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2142-10-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1208081, "text": " 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate RLL consolidation\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man s/p trauma with RLL consolidation\n REASON FOR THIS EXAMINATION:\n please evaluate RLL consolidation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n Comparisons were made with prior chest radiographs through \n with the most recent from .\n\n TECHNIQUE: Portable semi-erect upright radiograph of chest. Comparisons were\n made with prior chest radiographs through .\n\n FINDINGS: Tip of the endotracheal tube terminates approximately 5.5 cm above\n the carina. Left subclavian line ends at mid SVC. Since ,\n right lung opacities concerning for aspiration have improved, whereas on the\n left side they are unchanged. There are no new lung opacities.Left\n retrocardiac opacity suggesting lower lung atelectasis is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-07 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 1207770, "text": " 7:14 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: LUE SWELLING EVAL FOR DVT\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with LUE swelling\n REASON FOR THIS EXAMINATION:\n ?dvt\n ______________________________________________________________________________\n WET READ: KKgc SUN 10:51 AM\n No DVT in the left upper extremity.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man with left upper extremity swelling, to rule out\n DVT.\n\n COMPARISON: None available.\n\n FINDINGS: Grayscale and Doppler son of left internal jugular,\n subclavian, axillary, brachial veins were performed. There is normal\n compressibility, flow and augmentation throughout. The left cephalic and\n basilic veins are normal.\n\n IMPRESSION: No evidence of DVT in the left upper extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207445, "text": " 8:54 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: e/f IPH, SAH - please perform around 22:00 on \n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man s/p MCC\n REASON FOR THIS EXAMINATION:\n e/f IPH, SAH - please perform around 22:00 on \n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:02 PM\n 1. Interval increase in multifocal intraparenchymal hemorrhage, as described\n above.\n\n 2. Redemonstration of right orbital/maxillary sinus fractures, with\n hyperdense opacification of the right maxillary sinus.\n\n 3. No increased mass effect, including no evidence of midline shift or\n central brain herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVC with intracranial hemorrhage. Assess for interval change.\n\n COMPARISON: at 14:40 hours.\n\n NON-CONTRAST HEAD CT:\n\n There has been interval increase in multifocal intraparenchymal hemorrhage.\n For example, a hemorrhage at the right frontal vertex previously measuring 1.5\n x 1.0 cm now measures up to 3.0 x 2.5 cm. Additional hemorrhage in the left\n basal ganglia is also increased, for example, a focus previous measuring 10 x\n 7 mm, now measuring 14 x 10 mm. There is also new intraparenchymal hemorrhage\n identified in the left temporal lobe. Equivocal focus of subarachnoid blood\n in the left frontal region is also unchanged. Previously described thickening\n of the left tentorium is not well visualized on this study.\n\n There is minimal vasogenic edema adjacent to these foci of hemorrhage. There\n is local mass effect upon the sulci, without shift of midline structures or\n evidence of central brain herniation. The basal cisterns remain patent.\n Ventricles are unchanged in size. There is no CT evidence of vascular\n territorial infarction.\n\n The mastoid air cells remain well aerated. Hyperdense opacification of the\n right maxillary sinus, compatible with hemorrhage, with associated right\n orbital and right maxillary sinus fractures, as previously described, is again\n seen. There is overlying periorbital right soft tissue contusion.\n\n IMPRESSION:\n\n 1. Interval increase in multifocal intraparenchymal hemorrhage, as described\n above.\n\n (Over)\n\n 8:54 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: e/f IPH, SAH - please perform around 22:00 on \n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Redemonstration of right orbital/maxillary sinus fractures, with\n hyperdense opacification of the right maxillary sinus.\n\n 3. No increased mass effect, including no evidence of midline shift or\n central brain herniation.\n\n Discussed with Dr. at 10:00 p.m. by Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207446, "text": ", J. TSICU 8:54 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: e/f IPH, SAH - please perform around 22:00 on \n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man s/p MCC\n REASON FOR THIS EXAMINATION:\n e/f IPH, SAH - please perform around 22:00 on \n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Interval increase in multifocal intraparenchymal hemorrhage, as described\n above.\n\n 2. Redemonstration of right orbital/maxillary sinus fractures, with\n hyperdense opacification of the right maxillary sinus.\n\n 3. No increased mass effect, including no evidence of midline shift or\n central brain herniation.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-14 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1208881, "text": ", J. TSICU 6:00 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n Reason: concern for subdiaphragmatic abscess, leak from g-tube site\n Admitting Diagnosis: BLUNT TRAUMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with TBI s/p peg with hiccups\n REASON FOR THIS EXAMINATION:\n concern for subdiaphragmatic abscess, leak from g-tube site\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Worsening bibasilar consolidations.\n 2. Status post PEG tube placement without evidence of free air or\n extraluminal contrast.\n 3. Multiple rib fractures.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-06 00:00:00.000", "description": "L FOREARM (AP & LAT) LEFT", "row_id": 1207689, "text": " 1:38 PM\n FOREARM (AP & LAT) LEFT; ELBOW (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: ?fractures\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with s/p mcc w/ L elbow/forearm swelling concerning for\n compartment syndrome\n REASON FOR THIS EXAMINATION:\n ?fractures\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Motorcycle accident, swelling left elbow and forearm.\n\n No effusion is present in the left elbow, no fracture or dislocation is seen.\n\n LEFT FOREARM: No fracture or dislocation is seen. The alignment with the\n carpal bones appears anatomic.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207783, "text": " 9:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: e/f progression of SDH/ICH\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man s/p MCC\n REASON FOR THIS EXAMINATION:\n e/f progression of SDH/ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man status post MVC, to assess interval progression\n of known intracranial hemorrhage.\n\n COMPARISON: CT of the head without contrast, .\n\n TECHNIQUE: Contiguous axial images were acquired through the head without\n intravenous contrast.\n\n FINDINGS: Again seen are multiple evolving intraparenchymal hematomas,\n without significant interval change in size since the prior study of\n . There is mild interval increase in the edema surrounding these\n hemorrhagic contusions, especially surrounding the large hematoma in the right\n frontal vertex. The large right frontal vertex hematoma now measures 2.8 x\n 2.3 cm, which allowing for differences in technique is unchanged since the\n prior study 3.0 x 2.2 cm. Mild effacement of the right frontal hemispheric\n sulci, is more prominent since the prior study. No significant shift of\n midline structures is seen. Multiple parenchymal hematomas in the left\n frontal lobe, left caudate nucleus, basal ganglia, temporal lobe, are again\n redemonstrated. No new intracranial hematoma is seen. The ventricles and\n sulci are unchanged in appearance. There is no intraventricular extension of\n hemorrhage. The basal cisterns are normal. Multiple facial fractures\n including right superolateral orbital fracture, right orbital floor fracture\n are again redemonstrated. There is diffuse opacification of the right\n maxillary, right ethmoid sinuses, with air-fluid levels in both sphenoid\n sinuses.\n\n IMPRESSION:\n 1. Evolving intraparenchymal hematomas, without significant interval change\n in size. Mildly increased surrounding edema and mass effect.\n 2. No evidence of transtentorial herniation. No new parenchymal hematomas.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-14 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 1208879, "text": " 5:59 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: please evaluate for persistent sinus injury, status of right\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with facial fractures\n REASON FOR THIS EXAMINATION:\n please evaluate for persistent sinus injury, status of right orbit\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc SUN 10:36 PM\n 1. Multiple right facial fractures including right superior, inferior orbital\n wall and anterior wall of the right maxillary sinus.\n 2. No evidence of herniation of the orbital contents. Globes intact.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man with facial fractures, to evaluate interval\n change.\n\n COMPARISON: CT head without contrast .\n\n TECHNIQUE: MDCT helical images were acquired through the facial bones without\n intravenous contrast. Sagittal and coronal reformats are generated and\n reviewed.\n\n FINDINGS: Again seen is a comminuted fracture involving the right orbital\n floor, with near complete opacification of the right maxillary sinus with\n blood products. There is no evidence of entrapment of the orbital muscles or\n fat. Additional subtle nondisplaced fracture seen involving the anterior wall\n (2:18) of the right maxillary sinus. A comminuted fracture involving the\n superolateral aspect of the right orbit, orbital rim and lateral wall, (2:34)\n is unchanged. In comparison to the prior study, there is mild interval\n decrease in the right periorbital soft tissue hematoma. The globes are\n intact. No intraconal hematoma is seen. The left maxillary sinus is well\n aerated. Minimal mucosal thickening is seen in the right sphenoid and right\n frontal sinus. There is partial opacification of the right mastoid air cells.\n No other fractures are identified.\n\n IMPRESSION:\n 1. Multiple right facial fractures including right superior, inferior orbital\n wall and anterior wall of the right maxillary sinus.\n 2. No evidence of herniation of the orbital contents.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-14 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1208880, "text": " 6:00 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n Reason: concern for subdiaphragmatic abscess, leak from g-tube site\n Admitting Diagnosis: BLUNT TRAUMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with TBI s/p peg with hiccups\n REASON FOR THIS EXAMINATION:\n concern for subdiaphragmatic abscess, leak from g-tube site\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc SUN 8:36 PM\n Study is significantly limited by motion.\n 1. Interval improvement in the pulmonary contusion in the right upper and\n lower lobes. Tracheostomy tube in place. New focal eventration of the R\n hemidipahragm at the site of the previously seen contusion in the anterior\n basal segment of the right lower lobe.\n 2. New bilateral dependent lower lobe consolidations, likely atelectasis and\n aspiration. No pleural effusions or pneumothorax.\n 3. No subdiaphragmatic abscess. G tube in the stomach. No evidence of\n extraluminal contrast. Moderate fecal loading of the colon. No free air.\n 4. Multiple rib fractures, R third and fifth. Left-anterior second and third\n ribs. Kkaliann. wet read in ccc.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh MON 1:16 PM\n 1. Worsening bibasilar consolidations.\n 2. Status post PEG tube placement without evidence of free air or\n extraluminal contrast.\n 3. Multiple rib fractures.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 32-year-old male with traumatic brain injury status post PEG tube\n placement, now with hiccups, concerning for subdiaphragmatic pathology.\n\n STUDY: CT of the chest and abdomen with contrast; MDCT images were generated\n through the chest and abdomen after administration of 130 cc of Optiray\n intravenous contrast. Oral contrast was also administered through the G-tube.\n Coronal and sagittal reformatted images were also generated.\n\n COMPARISON: .\n\n FINDINGS:\n\n CHEST: The visualized portion of the thyroid is unremarkable. There is no\n axillary, hilar, or mediastinal lymphadenopathy. A tracheostomy tube is in\n place. The aorta is of a normal caliber along its course without evidence of\n injury. The pulmonary artery shows no large central filling defect. There is\n no pericardial effusion.\n\n Assessment of fine detail of the lungs is slightly limited by mild motion\n artifact. Bibasilar consolidations have worsened compared to prior study.\n Additionally, the previously described right lower lobe anterior basal segment\n (Over)\n\n 6:00 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n Reason: concern for subdiaphragmatic abscess, leak from g-tube site\n Admitting Diagnosis: BLUNT TRAUMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n contusion demonstrates a more confluent well-rounded appearance, possibly\n representing rounded atelectasis or a focal area of diaphragmatic eventration\n (2:45), measuring 26 x 17 mm. There is no large pleural effusion or\n pneumothorax.\n\n ABDOMEN: A gastrostomy tube is in place. Extensive streak artifact is seen\n from the oral contrast administered as well as from excreted IV contrast in\n the renal collecting systems. There is no evidence of extraluminal contrast\n or free air. There is no perihepatic or perisplenic fluid. The kidneys\n enhance with and excrete contrast symmetrically. The visualized portion of\n large and small bowel show significant colonic fecal load. The aorta shows no\n evidence of injury.\n\n BONES: Again are seen fractures of the anterior portions of the left second\n and third ribs as well as the anterior portions of the right second, third,\n fourth, fifth, and sixth ribs.\n\n IMPRESSION:\n 1. Worsening bibasilar consolidations as described above.\n 2. Status post PEG tube placement without evidence of free air or\n extraluminal contrast.\n 3. Multiple rib fractures as described above.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1207678, "text": " 11:26 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with new left subclavian CVL\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left subclavian line placed, check position.\n\n CHEST: The tip of the left subclavian line lies in the mid SVC.\n\n There is no pneumothorax. The endotracheal tube remains in satisfactory\n position, as does the nasogastric tube.\n\n Early opacities are seen in both the right and left base, which could\n represent aspiration.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-12 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1208609, "text": " 9:53 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: please evaluate for DVT\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with TBI and hypoxia concerning for PE\n REASON FOR THIS EXAMINATION:\n please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: TBI and hypoxia; now with symptoms concerning for PE.\n\n COMPARISON: None available.\n\n TECHNIQUE: Bilateral lower extremity ultrasound with Doppler.\n\n FINDINGS: -scale and Doppler son of bilateral common femoral,\n superficial femoral, popliteal, posterior tibial and peroneal veins were\n performed. There is normal compressibility, flow and augmentation.\n\n IMPRESSION: No evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-04 00:00:00.000", "description": "R FOREARM (AP & LAT) RIGHT", "row_id": 1207386, "text": ", EU 2:52 PM\n FOREARM (AP & LAT) RIGHT; ELBOW (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: eval for injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 yo m s/p MCC, helmeted, + loc, medium velocity. Intubated in ED\n REASON FOR THIS EXAMINATION:\n eval for injury\n ______________________________________________________________________________\n PFI REPORT\n Right elbow joint effusion suggests a radial head fracture, possibly at the\n outer aspect (nondisplaced). Irregularity of the ulna as described above -\n additional nondisplaced fracture is not excluded.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-04 00:00:00.000", "description": "R TIB/FIB (AP & LAT) RIGHT", "row_id": 1207387, "text": " 2:52 PM\n TIB/FIB (AP & LAT) RIGHT Clip # \n Reason: eval for injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 yo m s/p MCC, helmeted, + loc, medium velocity. Intubated in ED\n REASON FOR THIS EXAMINATION:\n eval for injury\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 30-year-old male status post motorcycle accident while wearing a\n helmet. Loss of consciousness.\n\n STUDY: Two views of the right tibia-fibula.\n\n COMPARISON: None.\n\n FINDINGS: There is no fracture or dislocation. No soft tissue abnormalities\n seen.\n\n IMPRESSION: No fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1208524, "text": " 4:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p trach placement\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with MCC\n REASON FOR THIS EXAMINATION:\n s/p trach placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Tracheostomy tube placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n tracheostomy tube. The tube is in correct position. Unchanged position of\n the left subclavian line. No evidence of complications.\n\n The pre-existing right and left lower lobe opacities are unchanged in extent\n and severity. Presence of a small left pleural effusion cannot be excluded.\n Borderline size of the cardiac silhouette, mild pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-04 00:00:00.000", "description": "R FOREARM (AP & LAT) RIGHT", "row_id": 1207385, "text": " 2:52 PM\n FOREARM (AP & LAT) RIGHT; ELBOW (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: eval for injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 yo m s/p MCC, helmeted, + loc, medium velocity. Intubated in ED\n REASON FOR THIS EXAMINATION:\n eval for injury\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh FRI 12:31 AM\n Right elbow joint effusion suggests a radial head fracture, possibly at the\n outer aspect (nondisplaced). Irregularity of the ulna as described above -\n additional nondisplaced fracture is not excluded.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 30-year-old male status post motorcycle accident.\n\n STUDY: Two views of the right elbow, two views of the right forearm.\n\n COMPARISON: None.\n\n FINDINGS:\n\n Views of the elbow demonstrate subtle outward bowing of the anterior fat pad.\n No definite posterior fat pad is identified, though evaluation is limited by\n overlying lines from the table.\n\n On the frontal view the elbow, there may be a cortical irregularity of the\n outer aspect of the radial head with an obliquely oriented linear lucency that\n may represent a subtle non-displaced fracture.\n\n Additionally, a cortical irregularity of the posterior proximal ulna is seen,\n subjacent to an area of laceration, likely representing a fracture.\n\n No radio-opaque foreign body is noted embedded in the soft tissues.\n\n IMPRESSION: Right elbow joint effusion suggests a nondisplaced radial head\n fracture. Irregularity of the ulna subjacent to a laceration likely\n represents a nondisplaced fracture.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1208256, "text": " 4:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: progression\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with pna\n REASON FOR THIS EXAMINATION:\n progression\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of pneumonia.\n\n Portable AP radiograph of the chest was reviewed in comparison to , .\n\n Right lower lobe consolidation has increased in the interim as well as the\n left lower lobe consolidation. Interstitial pulmonary edema is moderate,\n unchanged. Supporting devices are unchanged. Bilateral pleural effusion is\n most likely present.\n\n IMPRESSION: Interval progression of bibasal consolidations.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-10-16 00:00:00.000", "description": "RP FOREARM (AP & LAT) RIGHT PORT", "row_id": 1209196, "text": " 2:09 PM\n FOREARM (AP & LAT) RIGHT PORT; ELBOW (AP, LAT & OBLIQUE) RIGHT PORTClip # \n Reason: change in fx\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with fx\n REASON FOR THIS EXAMINATION:\n change in fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Change in fracture.\n\n RIGHT FOREARM, TWO VIEWS.\n\n There is soft tissue prominence adjacent to the distal diaphysis of the right\n ulna. There is a notch along the dorsal aspect of the proximal ulna, which\n could represent sequela of previous trauma -- this lies at the edge of these\n films and is not completely evaluated on these views. Otherwise, no fracture\n or focal lytic or sclerotic lesion is detected involving the radius or ulna.\n Equivocal small elbow joint effusion. Limited assessment of the right wrist\n and elbow joint is otherwise grossly unremarkable.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1207895, "text": " 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f pneumonia\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man s/p MCC, with suspected aspiration pneumonia\n REASON FOR THIS EXAMINATION:\n e/f pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 32-year-old man status post trauma with suspected\n aspiration pneumonia.\n\n COMPARISON: .\n\n FINDINGS: In comparison to the prior examination, the ET tube and subclavian\n line are in unchanged, correct position. The cardiomediastinal silhouette is\n unremarkable. At the right lower lung, there is an increase in the opacities\n seen on the prior study. The left lung atelectasis appears improved since\n prior study.\n\n IMPRESSION:\n Increasing right lower lobe opacities consistent with aspiration/infection.\n\n" }, { "category": "Radiology", "chartdate": "2142-10-06 00:00:00.000", "description": "B HUMERUS (AP & LAT) BILAT", "row_id": 1207690, "text": " 1:39 PM\n HUMERUS (AP & LAT) BILAT Clip # \n Reason: ?fractures\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with s/p mcc\n REASON FOR THIS EXAMINATION:\n ?fractures\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Motorcycle accident, pain by both shoulders.\n\n RIGHT HUMERUS AND SHOULDER, THREE VIEWS: No fracture or dislocation of the\n right shoulder or humerus is present.\n\n LEFT SHOULDER AND HUMERUS: No fracture or dislocation of the left humerus or\n shoulder is present.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2154-11-27 00:00:00.000", "description": "Report", "row_id": 82367, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Mitral valve disease. Mitral valve prolapse.\nWeight (lb): 150\nBP (mm Hg): 100/70\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 13:47\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement. Mild spontaneous echo contrast in the body\nof the LA. Mild spontaneous echo contrast in the LAA. Depressed LAA emptying\nvelocity (<0.2m/s) No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Myxomatous mitral\nvalve leaflets. Moderate/severe MVP. Partial mitral leaflet flail. Severe (4+)\nMR. Eccentric MR jet.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). No TEE related complications. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. The patient\nwas under general anesthesia throughout the procedure. The rhythm appears to\nbe atrial fibrillation. Results were personally reviewed with the MD caring\nfor the patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is markedly dilated. Mild spontaneous echo contrast is seen in\nthe body of the left atrium and in the left atrial appendage. The left atrial\nappendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the\nleft atrial appendage. A patent foramen ovale is present.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Overall LVEF 50 to 55%\nRight ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen.\nThe mitral valve leaflets are moderately thickened. The mitral valve leaflets\nare myxomatous. There is moderate/severe mitral valve prolapse of both the\nleaflets and there is partial posterior mitral leaflet flail. Severe (4+)\nmitral regurgitation is seen. The mitral regurgitation jet is eccentric.\nThere is no pericardial effusion.\nPOST_BYPASS:\nPreserved normal right ventricular systolic function.\nMild global LV hypokinesis on epinephrine infusion at 0.02mcg/kg/min. LVEF 45%\nA bioprosthetic valve is well seated and stable in the mitral position with no\nresidual regurgitation or stenosis.\nAortic contour is well preserved.\nMild TR and no AI.\n\n\n" }, { "category": "ECG", "chartdate": "2154-11-27 00:00:00.000", "description": "Report", "row_id": 207063, "text": "Technically difficult study\nSinus bradycardia\nVentricular couplet\nProlonged P-R interval\nST-T wave abnormalities\nClinical correlation is suggested\n\n" }, { "category": "Nursing/other", "chartdate": "2154-11-28 00:00:00.000", "description": "Report", "row_id": 1431274, "text": "7a-7p\n\nNeuro: alert and oriented x3. Incisional pain relieved with 1 Percocet. OOB to ch with 2 assist, moving well. Only up for about an hour- pt insisted on going back to bed.\n\nCV: SBP 110-120's. SR 70-80. APC's this am and ?bursts of svt.\nK repleted, Lopressor given, no further ectopy. CO >5, CI > 2,\nsv02 80, swan d/c'd. Left fem aline d/c'd. Rt radial aline d/c'd for ^bleeding from site. Pacer remains a demand 60. +pp.\n\nResp: Lungs clear. Using i/s to 650cc. Sats 98-100% on 3L nc.\nCTs to sxn draining ss, sm amts. ABG wnl.\n\nGI/GU: Abd soft, +bs, denies flatus. Appetite fair. Foley draining yellow urine, qs. RISS.\n\nSkin: see flowsheet\n\nSocial: Daughters in for better part of day.\n\nPlan: Cont to monitor hemodynamics/resp status. Pain control. D/C cordis in am after peripheral access established. D/C foley at 10pm.\nTransfer to f2 tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2154-11-29 00:00:00.000", "description": "Report", "row_id": 1431275, "text": "Neuro: pt alert oriented folowing commands. slept well through night\nResp: o2 sats 97% oin 2L NP coughing andraising small amounts.\nC/V: chest tubes patent draining serous sangunious drainage small amounts. no air leak noted. pt in a sinus rhythm with occasional bursts of afib converting right back to sinus. Good blood pressure tolerating lopressor 25mg po.\nGI: tolerating diet\nEndo: blood sugars marinally elevated covered with sliding scale insulin\nGU: adequate urine outputs. Good response to 20 mg iv lasixz.\nSkin: dsgs intact no drainage.\nActivity.Bedrest for night increase activity during day.\nPlan: Ambulate D/c chest tubes transfer to 2 today.\n" }, { "category": "Nursing/other", "chartdate": "2154-11-27 00:00:00.000", "description": "Report", "row_id": 1431270, "text": "Resp Care\n\nPt admitted s/p MVR and currently vented on PSV 10/5 tol well with vt around 300-440 and RR in the mid to upper 20s. BS essentially clear with minimal secretions. WIll cont with wean as tol and make changes accordingly.\n" }, { "category": "Nursing/other", "chartdate": "2154-11-27 00:00:00.000", "description": "Report", "row_id": 1431271, "text": "a paced for underlying junctional to sr 60's. epi weaned off w great hemodynamics,svo2 & low (for her) filing pressures.usual volume given for bp support & correction of met. acidosis.slow to wake but mae x 4 to command. occas. restless in the bed but unable to lift head or extremities off the bed,falls asleep quickly when not stimulated.daughters in,questions answered. is designated spokesperson & recieved icu visitor guidelines.\n" }, { "category": "Nursing/other", "chartdate": "2154-11-28 00:00:00.000", "description": "Report", "row_id": 1431272, "text": "Neuro: pt alert following commands, unable to assess orientation 2nd to intubation.\nResp: Pt on Cpap with ips all night. Tolerating well with good abg's awaiting extubation this am. Good abg's. suctioned for none.\nC/V: vss pt apaced with occasional bursts of afib self limiting. Pacer turned down this am rate in the 70's with good BP. pacer placed on ademand of 60.\n Blood pressure 120-140's no drips required. Good pulses in feet. Svo2 70's with CI >3. Chest tubes draining minimal amounts of serous sangunious drainage.\nGI: npo\nEndo: insulin gtt restarted at 2un/hr decreased to 1 unit and now off for blood sugar in the 70's.\nGU: urine outputs trending down 20-25cc/hr.\nSkin: incision clean and dry.\nPlan: Lasix, extubation ooB to chair. Possible transfer later today.\n" }, { "category": "Nursing/other", "chartdate": "2154-11-28 00:00:00.000", "description": "Report", "row_id": 1431273, "text": "Respiratory Therapy\n Pt presents orally intubated BS clear Bilat. Pt extubated @ 0635 to .4 cool aerosol. + cuff leak pre ext. Good phonation post ext. No stridor noted.\n" }, { "category": "Radiology", "chartdate": "2154-11-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 938648, "text": " 4:21 PM\n CHEST (PA & LAT) Clip # \n Reason: heart failure\n Admitting Diagnosis: MITRAL VALVE DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with MR\n REASON FOR THIS EXAMINATION:\n heart failure\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, PA AND LATERAL\n\n History of mitral regurgitation.\n\n No previous studies for comparison. There is cardiomegaly with probable\n biventricular and left atrial enlargement and slight pulmonary engorgement\n with small bilateral pleural effusions consistent with CHF. There is\n atelectasis at the right lung base. No previous studies for comparison.\n\n IMPRESSION: Cardiomegaly with CHF and small bilateral pleural effusions with\n right basilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-12-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 939549, "text": " 3:38 PM\n CHEST (PA & LAT) Clip # \n Reason: eval post op, atel.\n Admitting Diagnosis: MITRAL VALVE DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p MVR\n REASON FOR THIS EXAMINATION:\n eval post op, atel.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, PA AND LATERAL\n\n History of MVR.\n\n Status post MVR. Since the prior film of , the right-sided\n Cordis catheter has been removed. No pneumothorax. There are bibasilar\n atelectases and small bilateral pleural effusions, and linear atelectasis in\n the left mid zone. -apical pleural thickening.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-11-26 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 938714, "text": " 8:05 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: preop for MVR\n Admitting Diagnosis: MITRAL VALVE DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with MR\n REASON FOR THIS EXAMINATION:\n preop for MVR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This is an 81-year-old woman with MR.\n\n RADIOLOGIST: The exam was read by doctors and .\n\n TECHNIQUE: Evaluation of the extracranial carotid arteris was performed with\n B- mode, color and spectral Doppler ultrasound modes.\n\n FINDINGS: On the right peak systolic velocities are 74, 52, and 48 cm/sec, in\n the internal, common, external carotid arteries, respectively. The right ICA\n to CCA ratio is 1.42.\n\n On the left, peak systolic velocities are 81, 79, and 55 cm/sec, in the\n internal, common, and external carotid arteries respectively. The left ICA to\n CCA ratio is 1.02.\n\n Both vertebral arteries present with antegrade flow.\n\n COMPARISON: None available.\n\n IMPRESSION: There is no stenosis within bilateral internal carotid arteries.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-11-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 939204, "text": " 12:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: MITRAL VALVE DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p MVR and ct removal\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old, post-mitral valve replacement and chest tube\n removal, assess for pneumothorax.\n\n Portable upright frontal radiograph compared to .\n\n The endotracheal tube, NG tube, and bilateral chest tubes have been removed.\n The right IJ Swan-Ganz catheter has been exchanged for a Cordis catheter\n terminating at the confluence of the brachiocephalic and SVC. There may be a\n tiny residual left apical pneumothorax. Lung volumes are slightly reduced\n with atelectasis at both lung bases and linear atelectasis in the left mid\n lung zone. There may be a small left pleural effusion. Cardiac and\n mediastinal contours are stable.\n\n IMPRESSION: Low lung volumes and atelectasis. Possible tiny residual left\n apical pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2154-11-27 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 938901, "text": " 12:49 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: MITRAL VALVE DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p MVR\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 1:04 p.m. .\n\n INDICATION: Status post MVR. First post-op study.\n\n FINDINGS: The heart is mildly enlarged. No overt CHF. Mediastinum appears\n unremarkable allowing for supine position.\n\n The tip of the right IJ-PA catheter is coiled at the level of the main PA and\n is pointing back down the PA. Alternatively, this could have passed into the\n left PA and down into the descending left pulmonary artery, although the main\n PA position is more likely.\n\n The positions of the other tubes and catheters all appear unremarkable. There\n may be tiny bilateral apical pneumothoraces present when compared with the\n pre-op study of , but given the supine position of the patient at this\n time, these findings may be equivocal.\n\n IMPRESSION:\n\n 1. Possible tiny bilateral apical pneumothoraces.\n\n 2. Probable malposition of the PA catheter at the level of the main pulmonary\n artery bifurcation. This finding was discussed with Dr. .\n\n\n\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2137-05-18 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 961801, "text": " 3:02 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval for contrast in kidneys\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with ARF, concern for contrast nephropathy.\n REASON FOR THIS EXAMINATION:\n eval for contrast in kidneys\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, SINGLE VIEW, AT 1529 HOURS.\n\n HISTORY: Acute renal failure with concern for contrast nephropathy. Assess\n for contrast excretion.\n\n FINDINGS: Single portable view of the abdomen is compromised secondary to\n body habitus. There is loss of the properitoneal fat stripes and central\n clumping of the gas distended loops of bowel consistent with ascites. No\n contrast is noted overlying the expected locations of the kidneys or ureters.\n Oral contrast is noted in the distal colon including the rectum and therefore\n obscures the bladder.\n\n IMPRESSION: Ascites with retained oral contrast in the distal colon and\n rectum. No contrast seen corresponding to renal fossae or course of ureters.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961448, "text": " 5:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with altered MS now with fever to 101.8\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old female with altered mental status with increasing fever.\n\n Comparison is made to prior CT examination dated , and prior\n radiograph dated .\n\n ERECT PORTABLE CHEST RADIOGRAPH:\n\n FINDINGS: Since most recent supine film on CT examination there has been\n interval development of dense retrocardiac opacity obscuring the left\n hemidiaphragm as well as obscuration of the right hemidiaphragm likely\n reflective of worsening bilateral pleural effusions and atelectasis. No frank\n pulmonary edema or pneumothorax is identified. Heart size remains enlarged.\n New tube over mid abdomen may represent a J tube.\n\n IMPRESSION:\n Probable worsening of bilateral pleural effusions with new left lower lobe\n opacity. Given rapidity of onset atelectasis or aspiration pneumonitis is\n favored over rapid developing pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-14 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 961254, "text": " 11:33 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: HX IVDU\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Field of view: 36 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with altered mental status, neck pain, Hx of IVDU,\n pancytopenia, Left upper abdominal pain, and hypoxia\n REASON FOR THIS EXAMINATION:\n eval for hepatomegally, splenomegally, PNA, PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST, ABDOMEN AND PELVIS\n\n CLINICAL HISTORY: 46-year-old woman with altered mental status, neck pain.\n History of IVDU, pancytopenia, left upper abdominal pain and hypoxia. Evaluate\n for hepatomegaly, splenomegaly, pneumonia, pulmonary embolism.\n\n Comparison made to prior studies, the most recent dated .\n\n TECHNIQUE: Multiple transaxial images of the chest, abdomen and pelvis were\n obtained. Pre- and post-contrast images of the chest were obtained, utilizing\n the pulmonary embolism protocol. Additional post-contrast images of the\n abdomen and pelvis were also obtained, as well as coronally and sagittally\n reformatted images.\n\n CT CHEST: Evaluation is limited secondary to multiple factors, including low\n radiation technique, the patient's arms by her sides and body habitus.\n\n No intraluminal filling defects are seen in the main pulmonary artery or its\n proximal branches. The pulmonary artery is enlarged, measuring 3.3 cm,\n suggesting the presence of pulmonary arterial hypertension. The aorta is\n normal in caliber, without evidence of dissection or aneurysmal dilatation.\n\n There are small bilateral pleural effusions with adjacent airspace disease,\n likely representing atelectasis. No hilar, mediastinal or axillary\n lymphadenopathy. No pericardial effusions.\n\n Endotracheal tube and nasogastric tube are in place.\n\n CT ABDOMEN: Limited evaluation of the abdomen demonstrates a slightly nodular\n contour of the liver and morphologic changes, consistent with cirrhosis. The\n patient is post-cholecystectomy. The spleen is markedly enlarged. There are\n splenic varices. The pancreas, adrenal glands and kidneys are grossly normal.\n The bowel is unremarkable.\n\n No intra-abdominal fluid collections are identified. No significant abdominal\n free fluid. No markedly enlarged abdominal or retroperitoneal lymph nodes are\n seen.\n\n (Over)\n\n 11:33 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: HX IVDU\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Field of view: 36 Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT PELVIS: There is a Foley catheter within the urinary bladder. The rectum\n and sigmoid colon are unremarkable. No pelvic or inguinal lymphadenopathy or\n free fluid.\n\n No suspicious osseous lesions.\n\n A bone island is in the L5 vertebral body.\n\n Findings were discussed with physician taking care of the patient by the on-\n call Radiology resident.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism, as clinically questioned. Enlarged\n pulmonary artery, compatible with pulmonary arterial hypertension.\n\n 2. Bilateral pleural effusions with adjacent airspace disease, likely\n representing atelectasis.\n\n 3. Findings consistent with cirrhosis with associated splenomegaly likely\n reflecting portal hypertension.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-14 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 961255, "text": " 11:34 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: eval for neck abscess/mass\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with altered mental status, neck pain Hx of IVDU,\n pancytopenia\n REASON FOR THIS EXAMINATION:\n eval for neck abscess/mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MMBn WED 12:56 AM\n 1. No fluid collections or abscesses. No pathologically enlarged lymph\n nodes.\n 2. ETT cuff is slightly overinflated without pneumomediastinum.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old female with altered mental status, neck pain and\n history of IV drug use, now with pancytopenia.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT imaging of the neck was performed following the\n administration of 50 cc of intravenous Optiray.\n\n Endotracheal and orogastric tubes are in place. The endotracheal tube cuff\n appears overinflated. There are no fluid collections or abscesses within the\n soft tissues of the neck. The muscular and fat planes are preserved, without\n evidence of inflammation. There are no pathologically enlarged lymph nodes.\n All major vessels enhance normally. The density lesions in both thyroid\n lobes, with scattered coarse calcifications are likely benign. The lung\n apices are clear. There are no findings concerning for malignancy within the\n imaged bones.\n\n IMPRESSION:\n\n 1. No fluid collections or abscesses are identified within the neck. There\n are no pathologically enlarged lymph nodes.\n\n 2. Endotracheal tube cuff appears slightly overdistended, with no adjacent\n pneumomediastinum.\n\n 3. Bilateral hypodense thyroid nodules, with scattered coarse calcifications\n are likely benign. Thyroid ultrasound could be performed on a nonemergent\n basis if clinically indicated.\n\n (Over)\n\n 11:34 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: eval for neck abscess/mass\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2137-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961738, "text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls eval for interval progression of pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with altered MS w/fevers and known PNA\n REASON FOR THIS EXAMINATION:\n Pls eval for interval progression of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status with fevers and no pneumonia, for followup.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH: Compared to the prior study, there has been improvement\n of the left lower lobe opacity. The cardiac silhouette is within normal\n limits. The pulmonary vascularity is normal in appearance. The right\n hemidiaphragm remains obscured, unchanged. There are low lung volumes.\n\n IMPRESSION: Improving left basilar atelectasis but unchanged right basilar\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-19 00:00:00.000", "description": "R SHOULDER 2-3 VIEWS NON TRAUMA RIGHT", "row_id": 961897, "text": " 3:18 PM\n SHOULDER VIEWS NON TRAUMA RIGHT Clip # \n Reason: eval for fluid collection\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman admitted with fever and delirium now with ecchymosis to R\n shoulder, ? s/p fall.\n REASON FOR THIS EXAMINATION:\n eval for fluid collection\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT SHOULDER THREE VIEWS, AT 15:26 HOURS\n\n HISTORY: Ecchymosis to right shoulder with question of fall.\n\n COMPARISON: None.\n\n FINDINGS: There is no fracture or dislocation. The glenohumeral and\n acromioclavicular joints are within normal limits. The coracoclavicular\n interval is appropriate. The regional soft tissues radiographically are\n unremarkable. The visualized adjacent lung is clear.\n\n IMPRESSION: No radiographic evidence of traumatic bony injury to the\n shoulder. Please note, not mentioned above, there are very tiny curvilinear\n opacities in the region of the greater tuberosity which are likely due to\n calcific tendinitis and are not felt to be due to acute trauma.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 961253, "text": " 11:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ALTERED MS\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MMBn WED 12:30 AM\n No ICH or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old female with altered mental status.\n\n COMPARISON: Non-contrast head CT dated .\n\n TECHNIQUE: Routine non-contrast head CT.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, mass effect, or shift\n of normally midline structures. There is no major vascular territorial\n infarction. The density values of the brain parenchyma are within normal\n limits. The -white matter differentiation is preserved. The surrounding\n soft tissue and osseous structures are unremarkable. The visualized paranasal\n sinuses and mastoid air cells are clear.\n\n IMPRESSION: No intracranial hemorrhage or mass effect.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-17 00:00:00.000", "description": "ABDOMEN U.S. (PORTABLE)", "row_id": 961657, "text": " 11:19 AM\n ABDOMEN U.S. (PORTABLE) Clip # \n Reason: Pls eval for fluid. Pls eval with dopplers for flow.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with known hep C cirrhosis now w/abdominal pain\n REASON FOR THIS EXAMINATION:\n Pls eval for fluid. Pls eval with dopplers for flow.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old woman with known hepatitis C, now with abdominal pain,\n evaluate for fluid, evaluate Dopplers for flow.\n\n TECHNIQUE: Son images of the abdomen are submitted for\n interpretation.\n\n Findings are compared with recent prior CT dated .\n\n FINDINGS: The liver is markedly heterogeneous, without focal hepatic lesions\n seen. There is no intra- or extra-hepatic biliary dilatation. The common\n bile duct measures 0.4 cm. The patient is status post cholecystectomy. The\n pancreatic head and uncinate process are unremarkable. The distal tail is\n obscured by overlying bowel gas. There is patent hepatopetal flow within the\n liver.\n\n Doppler evaluation of the portal veins demonstrate a widely patent portal vein\n with velocity of 25 cm/sec. The IVC is widely patent. The hepatic veins are\n unremarkable and widely patent. Examination of Doppler patency is slightly\n limited due to patient inability to hold her breath. The hepatic arteries are\n widely patent with resistive indices of 0.67.\n\n The right kidney is unremarkable in size and displays no evidence for\n hydronephrosis. Please refer to concurrently performed renal ultrasound for\n further evaluation of the kidneys. Limited evaluation of the abdominal aorta\n demonstrates no evidence for aneurysm.\n\n IMPRESSION:\n 1. Markedly heterogeneous echotexture of the liver compatible with known\n cirrhosis in this patient with hepatitis C.\n 2. Widely patent Doppler interrogation of the portal vein, hepatic artery,\n and hepatic veins.\n\n\n" }, { "category": "Radiology", "chartdate": "2137-05-17 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 961658, "text": " 11:19 AM\n RENAL U.S. PORT Clip # \n Reason: Pls eval for obstruction\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with known hep C cirrhosis with acute renal failure\n REASON FOR THIS EXAMINATION:\n Pls eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old woman with known hepatitis C cirrhosis with acute renal\n failure, please evaluate.\n\n TECHNIQUE: Multiple son images of bilateral kidneys are submitted for\n interpretation. The bladder is not well visualized due to Foley catheter in\n place.\n\n FINDINGS: The right kidney measures 12.0 cm. The left kidney measures 16 cm.\n There is no intrarenal stone. No obstructing stones, masses or hydronephrosis\n is appreciated.\n\n IMPRESSION: Unremarkable evaluation of bilateral kidneys without evidence for\n hydronephrosis, obstructing stone or renal mass.\n\n" }, { "category": "Radiology", "chartdate": "2137-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961245, "text": " 8:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CM, tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with altered MS, s/p intubation\n REASON FOR THIS EXAMINATION:\n eval for PNA, CM, tube placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP portable chest x-ray.\n\n INDICATION: 46-year-old female with altered mental status, status post\n intubation. Assess for pneumonia.\n\n COMPARISONS: None.\n\n FINDINGS: The endotracheal tube is approximately 2 cm above the carina.\n There is dense opacification present at the retrocardiac space which could\n reflect underlying hiatal hernia or atelectasis. Overall, the lung volumes are\n low; however, the lungs are clear. There is no large pleural effusion.\n\n IMPRESSION:\n\n 1. Recommend partial withdrawal of the endotracheal tube by at least 2 cm.\n\n 2. Increased density of the retrocardiac space could represent atelectasis\n versus underlying hiatal hernia. A lateral view, when feasible, might be of\n help.\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-16 00:00:00.000", "description": "Report", "row_id": 1369262, "text": "npn: 1900-0700\ncode status: full\n\nall: please see hcp\n\npmh: etoh, heroin abuser\n\nreason for admission: pt sent to from osh for ms changes\n\nsignifcant events: pt c/o abd and head continously. pt recieved dilaudid po times two throughout shift. pt is very lethargic but arouseable. pt will be sleeping and still c/o pain. pt bp has been marginal. pt uop has remained low throughout shift so pt recieved a total of 1500cc ns boluse and was placed on a maintance gtt of d51/2ns. pt spiked a temp 101.9. pt was pan cultured. pt recieved tylenol 1000mg. 0530 pt sats began to drop into the mid-high 80's. pt was placed back on face tent. pt is schedueled to be a c/o in am\n\nneuro: pt is alert and oriented but has confusion at times. pt is lethargic but arousable and will continually c/o pain. pt will follow commands. pt has cwia scale if needed.\n\ncv: bp 83-101. hr 80's. nsr. ppp bilateral. trace edema noted. pt may need a picc line d/t hard to find access.\n\nresp: pt was 3lnc throughout shift with sat 92 when sleeping and 96 when awake. pt rr was wnl untill this am when pt began coughing. pt started to desat so face tent was applied and rr was in the 30's. lungs clear and diminshed in bases. currenly sats are 97% and rr 22.\n\ngi/gu: pt on cl. pt abd is soft but distended. no bm. pt swallows pills. foley cath in place. pt had foley irrigated times two d/t low uop with no effect. 1500cc ns boluses given. uc/ua. pt denies any bladder pain or pressure.\n\ntmax 101.9 pan cultured.\n\nplan: monitor sats, pain, ms changes. pt is be c/o today\n" }, { "category": "Nursing/other", "chartdate": "2137-05-15 00:00:00.000", "description": "Report", "row_id": 1369259, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick tan secretions.Temp 99.8. Sedated withj propofol.RSBI done on 0 peep/5 ips 48.3.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-15 00:00:00.000", "description": "Report", "row_id": 1369260, "text": "NPN 7p-7a\nPt is 46y/o with h/o ETOH use, Hep C IVDU, opiate dependence, and known thrombocytopenia. Pt was transfered from OSH with MS changes, neck stiffness, and petechial rash. Pt recevied ABX in ED, and was electively intubated as MS and pt not cooperative, needing CT scan. Pt transfered to MICU for further management.\n\nNEURO: Pt is sedated on 50mcg Propofol, initially requiring frequent boluses to settle out. Pt now arouses to pain, does not follow commands. PERRL 2mm, brisk. Sedation to be turned off right before rounds for SBT.\n\nCV: NSR 90s, no ectopy. BP 130s-160s/80s. Palpable pulses bilaterlly.\n\nRESP: Pt currently intubated on AC 50%/500/14/5. RSBI on 0/5 was 48.3. Sats> 97%. LS coarse in bilateral upper lobes, diminished in bases. Suctioning scant thick tan secretions.\n\nGI/GU: ABD is softly distended, hypoactive BS. OGT to LWS, draining oral prep from CT scan, white mixed with some bilious drainage. Pt NPO. No stool. U/O adequate, foley draining 80cc/hr. Maintanence fluids @ 100cc/hr for 2.0L.\n\nSKIN: Pt has rash like scratches over chest and upper back, not really petechial in appearance. Pt's face is slightly reddened. Pt also has small scab like markings over arms and legs.\n\nSOCIAL: Pt lives with her son. husband died two years ago of CA. Per previous notes, pt uses heroin daily.\n\nPLAN: SBT this am with sedation lightened and extubate if doing well. Follow up with CT scan results. Cont empiric menengitis treatment with ABX and acyclovir.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-15 00:00:00.000", "description": "Report", "row_id": 1369261, "text": "MICU7 RN NOTE 0700-1900\n\nEVENTS:Extubated at 10am, Urine tox pending, hematuria, agitation in times, c/o abd pain, hypokalemic,low grade temp.\n\nNeuro: Received pt sedated with profofol 40mcg/kg/min, weaned to off at 1000, Awake alert open eyes spontaneous, pupils 3-5mm react , random. Equal strength. Follows commands,intermittent agitation /restlessness, moving about in the bed and calling out. Pain management: c/o sharp LUQ pain , received morphine 1mg x2, dilaudid was 1-2.5mg IVP with effect. Pt sleeps comfortable. While awake c/o pain crying out for pain med. At 1700 c/o neck pain ?spasm seen by resident and received 2mg of haldol IV. Pt on routine clonazepam. CIWA SCALE 7-12 + Tremors UE. Plan to start on tizanidine 2mg .\n\nCV: HR 105-120 Sinus tachy, No ectopy. BP 110-125/85 MAPS >70. Peripheral pulses 3+ DP/DT Neg edeam. IV access started w/ 2PIV 1PIV NS 50cc/hr . Hypokalenia K+ 3.5 Repleted KCL 40meq/500cc @ 500cc/hr.\nHeme: Hct 31.4 + hematuria. Type and screen. IVNR 1.5\n\nResp: received intubated Ett 23 lip, vent Mode A/c %, 5 peep. SBT 0/5 50% 2hrs Abg 7.41 40-107-28 sats ^98%. Suctioned via ETT for sm amt thick yellow. Extubated @1000, O2 FT 50% ^ 70% desat 88% spont recovery congested cough expectorated thick yellow/swallows secretions. O2 wean NC 3L Sats 98%, LS coarse and diminished.\n\nGI: Abd soft LUQ pain palpation, BS+, no stool, NPO diet adv liq to diet as tol.\n\nGU: Foley urine 50-100cc/hr. Hematuria noted at 4pm it could be from she pulling the cath. Urine tox screen pending.\n\nDerm: Skin dry. Excoriation from itching on legs and shoulder. Moderate itching+ lotion applied.\n\nID: T-max 100.9, wbc 3.9 On Abx ceftriaxone,Acyclovir and vancomycin.\n\nSocial: Full code No family contact this shift.\n\nPlan: CiWA eval/ withdrawal start meds\n D/C foley\n Call out in am\n" }, { "category": "Nursing/other", "chartdate": "2137-05-16 00:00:00.000", "description": "Report", "row_id": 1369263, "text": "See and Carevue for detailed documentation\n\nNeuro: Patient very lethrgic. Slow to wake, when aroused patient is oriented x3, responds appropriately but difficult to keep awake. c/o pain in abd, but answers yes to question of pain in all locations. Pain medication held due to somnolence. Patient with CIWA scale 24, increased to 10 briefly with increased tremors, restlessness. Patient back in bed, asleep CIWA scale return to 1.\n\nResp: BS clear, diminished in bases. Weaned to RA with stable SAT.\nCXR with ? bilateral pleural effussion, ? infiltrate. Encourage OOB to chair, encourage to deep breathe. Became tachypneic with ?withdrawl/ inc CIWA scale. Self resolved. Remain very sleepy, difficult to instruct.\n\nCV: In NSR HR 80-100. BP with MAP ~60 in am. Now improved without pain med thru day. Afebrile. Cultures pending, Antibiotics change, acylovir done, cefazolin dose decreased for pnuemonia coverage, start po flagyl.\n\nGI/GU: Hypoactive bowel sounds. taking po well. c/o abd pain treated with colace/ senna without result. Urine output very poor in am despite fluid boluses. Output slowly improved with increased BP.\n\nSocial: No contact from family.\n\nPlan: Continue cardiopulmonary monitoring. Encourage pulmonary toilet. Continue to monitor CIWA scale. Hold pain medication for now.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-18 00:00:00.000", "description": "Report", "row_id": 1369270, "text": "Micu nursing note7-1900\n\nNeuro: pt A&Ox1 which had varried today, in am pt A&Ox3 but by noon pt not able to state where she was, also pt c/o pain this am at 730 has recieved po dilaudid was seen by resident and told she would need to wait until 9 am. pt recieved po dilaudid x2 today with good effect\nat 9 am pt crying and upset about not washing hair was agitated and required haldol 2 mg IV pt setteled down and slept for several hrs, by noon when seen by house staff pt agian getting agitated when asked questions, seem delusional tacky to 120, shakey no fever at that time ? if she was withdrawing for some med, pt placed on ciwa and was 11 at that time was then given 1 mg iv ativan, pt again feel asleep but was easy to arrouse, by this afternoon pt seems more calm still sleepy but wakes easy.\n\rcv : pt hemodynmically stable, pulses palp, hr 90-120 Bp 127-143/83-90\nresp: pt remain on 2l n/c sats 95-100% lungs crackles in bases\nGi abd soft, bowel sounds x4, pt had 2 soft stools,\nGU pt passing yellow urine via foley with sediment ua/c&s sent this afternoon, pt also seen by renal, they feel renal failer r/t dye studies\nID pt afebrile and anitbiotics now stopped\nheme pt still low 49\nskin noted bruesing on L shoulder which pt states she got that playing football with grandson.\nsocial no family today but resident will attempt to contact them today, also with hx of substance abuse consult placed for social service.\n\nA/P ATN, following unine output and labs\n alter mental status now on ciwa, pt at risk for asperation will continue with ativan as needed and haldol prn\nfollow up with family reguarding pt's drug use calls place to daughter but no return call from her. antibiotics will follow to see if she spikes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-05-19 00:00:00.000", "description": "Report", "row_id": 1369271, "text": "MICU NPN 7P-7A\nNEURO: INITIALLY AAOX2, UNCLEAR OF CITY SHE WAS IN. WAS RESTLESS, ANXIOUS AND MILDLY AGITATED. TREMORS NOTICABLE. CIWA WAS 10 AND RECEIVED 1MG ATIVAN IV. ALSO C/O ABD PAIN FOR WHICH SHE RECEIVED 1MG DILAUDID PO. ATTEMPTING TO PULL PT UP IN BED, SHE STARTED YELLING THAT SHE DIDN'T WANT TO BE PULLED UP AND WANTED TO GO HOME. PATIENT CRYING AND ATTEMPTING TO GET OOB. REDIRECTED AND SETTLED PT DOWN. NO NEED FOR HALDOL. BECOMES ANXIOUS AT TIMES BUT CIWA SINCE HAS BEEN <10. GOT OOB TO COMMODE WITH LITTLE ASSISTANCE. THIS MORNING AAOX3, C/O ABD PAIN AND GIVEN 1MG DILAUDID.\n\nCARDIAC: HR 87-104 SR/ST WITH NO ECTOPY. BP 128-161/68-97. HCT 26.3 PLTS 51. COAGS, FDP PENDING. NO SIGNS OF BLEEDING. PPP.\n\nRESP: ON 2L N/C WITH RR 17-25 AND SATS 95-99%. LS CLEAR WITH BIBASILAR CRACKLES. AFTER AUTODIURESING POSTERIOR LS CLEAR AND JUST DIMINISHED LEFT BASE. OCCASIONAL COUGH ?R/T PO FLUIDS AND POSSIBLE ASPIRATION. HAD ONE EPISODE WHEN SHE AWOKE, DISORIENTED AND STATED SHE COULDN'T BREATHE. BECAME TACHY AND SATS DROPPED TO LOW 90'S. RESOLVED QUICKLY AFTER REASSURANCE AND REORIENTATION.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. LGE BROWN SOFT STOOL X1. UOP 85-450CC/HR AMBER TO YELLOW AND CLEAR. EVENING CREAT WAS 3.9, AM PENDING.\n\nFEN: AUTODIURESING, +4.4L LOS. LYTES PER CAREVUE. HOUSE DIET AS TOLERATED.\n\nID: TMAX 99.1 WITH WBC 3. NOW OFF ALL ABX. NGTD ON URINE/BLOOD CX'S.\n\nSKIN: W/D/I.\n\nACCESS: PIV X1.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. MONITOR TEMPS AND CX'S, IF SPIKES ABX NEED TO BE RESTARTED...ENCOURAGE OOB AND IS...CONTINUE CIWA SCALE...POSSIBLE CALL OUT.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-17 00:00:00.000", "description": "Report", "row_id": 1369266, "text": "MICU NPN 3PM-11PM:\n46y.o. female admitted from OSH on w/change MS, pancytopenia. Has had waxing and mental status with periods of agitation/drug seeking behaviour alt w/somnolence. Gets small doses of dilaudid for c/o abdominal pain. Abdominal US done/Renal US results show ?chirrosis otherwise normal results.\n\nN: Sleepy most of the shift, wakes up and is somnolent with slow speech. Alert, oriented times two. Initially refused lactulose but when we told her MD was coming to put in NGT she took the lactulose without difficulty.\n\nCV: HR 90-100 sinus rhythm. BP 100-130's.\n\nResp: remains on O2 3L N/C with good sat. CXR shows possible LLL PNA and pt has started to develope SOB/exp wheezes with agitation. Started on PRN albuterol nebs. Lungs coarse and deminished. Cough weak and non-productive.\n\nGI: Ordered small diner but has not eaten yet. Worried about stooling after the lactulose and I explained she will need badpan tonight if she needs to stool.\n\nGU: Foley is in place and draining bloody urine at times. Adequate output. creat 3.5\n\nHeme: Pt with pancytopenia seen by heme/onc in consult who feel it is not TTP. Plt 34 today. Pt with slight nose bleed also. Hct 27.5\n\nID: afebrile on IV vanco and PO flagyl as well as IV ceftriaxone. WBC 2.7\n\nAccess: Pt has poor IV access and has one PIV in left upper arm. Also difficult stick for labwork. Team made aware.\n\nPlan: Continue to follow labs/vital signs closely. Continue to assess mental status/resp status closely. Try to limit sedatives. Give lactulose Q8hr until stooling.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-17 00:00:00.000", "description": "Report", "row_id": 1369267, "text": "Brief Addendum to NPN:\nPt has started to have results from lactulose and has been to commode twice and is currently using the bedpan since it takes so much energy to get upo to commode. Pt also c/o pain and received dilaudid PO as ordered in .\n" }, { "category": "Nursing/other", "chartdate": "2137-05-18 00:00:00.000", "description": "Report", "row_id": 1369268, "text": "respiratory care\npt seen for PRN neb tx.BS reveled mild exp wheezes.Albuterol neb given with fair effect.Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-18 00:00:00.000", "description": "Report", "row_id": 1369269, "text": "MICU NPN 11P-7A\nNEURO: INITIALLY PATIENT DIFFICULT TO AROUSE, LETHARGIC AND EVENTUALLY RESPONDED TO VOICE AND STIMULUS. AAOX2, UNCLEAR OF THE YEAR. FOLLOWED COMMANDS AND WAS ABLE TO TAKE PO MEDS SAFELY. THIS MORNING MORE ALERT, AAOX3, MOVING AROUND IN BED. C/O ABD PAIN AND WAS TREATED WITH 1MG OF DILAUDID PO. BEHAVIOR HAS BEEN APPROPIATE.\n\nCARDIAC: HR 93-116 SR/ST WITH NO ECTOPY. ST FEVER. BP 106-142/63-75. PPP. HCT 26.8. PLTS 49 UP FROM 34.\n\nRESP: ON 3L N/C WITH RR 17-23 AND SATS 95-97%. LS COARSE/CLEAR WITH FEW BIBASILAR CRACKLES. RARE COUGH. DENIES SOB. CXR DONE THIS MORNING. PREVIOUS CXR HAS LLL INFILTRATE, POSSIBLE ASPIRATION. ALSO KNOWN BILATERAL PLEURAL EFFUSIONS.\n\nGI/GU: ABD SOFT WITH +BS. ON BEDPAN X2 BUT NO STOOL. LIVER U/S ONLY WITH KNOWN CIRRHOSIS. UOP 30-50CC/HR YELLOW AND CLEAR. CREAT UP TO 4.1 FROM 3.5. RENAL U/S WAS NEGATIVE.\n\nFEN: +6.4L LOS, NO EDEMA. LYTES PER CAREVUE. ORDERED HOUSE DIET, TAKING FLUIDS OVERNOC WITHOUT DIFFICULTY.\n\nID: TMAX 101.1, BLD CX'S X2 SENT, GIVEN 650MG TYLENOL WITH TEMP DOWN TO 97.4. WBC 3.6.ON VANCO AND FLAGYL. CEFTRIAXONE WAS D/C'D AND LEVOFLOX STARTED. URINE CX NEGATIVE, BLOOD CX'S NGTD.\n\nSKIN; W/D/I.\n\nACCESS: PIV X1.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. MONITOR MS WITH LACTULOSE TODAY...MONITOR PLTS (HEME/ONC SAYS NO TTP)...MONITOR UOP...ABX AS ORDERED.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-17 00:00:00.000", "description": "Report", "row_id": 1369264, "text": "NPN 1900-0700:\nEvents: Pt c/o severe abdominal pain (sharp 10/10 per patient) given Dilaudid 2 mg PO as per PRN and as pt was so agitated and found at the side of the bed trying to get OOB by herself while very drowzy, given Haldol2 mg IV x1 PRN. Thereafter, because pt was so drowzy, HO recommended no more sedation/pain killer and Tizanidine was D/Ced in an attempt to let pt wake pt up.\n\nROS:\n\nNeuro: pt is sleepy most of the time, yet, when awake, she's alert and oriented x3, c/o severe abdominal pain controlled once by Dilaudid Po, thereafter by repositioning and positive reassurance, with no visible tremors, pakms mildly perspiring, with mild to moderate anxiety due to pain (pt has a hx of alcohol and drug abuse), CIWA scale 4-8.\n\nResp: Breathing with tachypnea on NC 3 LPM, RR 18-42, SPO2 90-96%, LS CTA on upper lobes and diminished over lower lobes.\n\nCV: NSR HR 76-117, BP 91-126/43-70, with a PIV line, palpable pulses, with edema over extremities especially upper extremities (Rt.Lt), elevated over pillows, receiving flagyl PO and ceftriaxone IV.\n\nGI/GU: on house diet well tolerated, abdomen soft, BS prtesent, with foley cath draining 25-70 cc/hr amber clear U/O.\n\nInteg: Skin integrity intact except for the edema, T max 99.8, cold compresses applied, T decreased to 97.5.\n\nSocial: pt is full code, ambulated to chair with help yesterday, no contact from family over night.\n\nPlan: Assess LOC, CIWA scale and pain level frequently, minimize sedative meds to make pt wake up more, continue antibiotics, monitor BP and U/O (may need fluid boluses if hypotensive or oliguric), pt can be called out when stabilized and a bed is available on a regular floor.\n" }, { "category": "Nursing/other", "chartdate": "2137-05-17 00:00:00.000", "description": "Report", "row_id": 1369265, "text": "This 46y/o female admitted with change in ms, neck stiffness & petichae rash was initially r/o menigits, now with pancytopenia, Hep C with lethargy, and cxr with LLL infiltrate on Vanco, ceftriaxone & ? of aspiration pna now experiencing sharp abdominal pain with elevated creatine with unknown etiology. Pt given po dilaudid - 1mg for pain at 1:30pm and repeat dose @2:30pm. renal and Abdominal U/S done - results (-). Pt remains with lethargy, arousable, yells out at times, continues to refuse lactulose for hepatic encephalopathy - team aware. Repeat vanco level elevated to 35, Vancomycin d/c'd\n" }, { "category": "ECG", "chartdate": "2137-05-22 00:00:00.000", "description": "Report", "row_id": 183141, "text": "Sinus rhythm. Normal ECG. Compared to the previous tracing of no\nchange.\n\n" }, { "category": "ECG", "chartdate": "2137-05-19 00:00:00.000", "description": "Report", "row_id": 183142, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , anterior ST-T wave abnormalities resolved\n\n" }, { "category": "ECG", "chartdate": "2137-05-14 00:00:00.000", "description": "Report", "row_id": 183143, "text": "Sinus rhythm\nDelayed R wave progression with late precordial QRS transition - may be in part\npositional/nonspecific\nNonspecific precorial/anterior T wave abnormalities\nSince previous tracing of the same date, delayed R wave progression with late\nprecordial QRS transition and probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2137-05-14 00:00:00.000", "description": "Report", "row_id": 183144, "text": "Sinus rhythm\nModest nonspecific precordial/anterior T wave changes\nSince previous tracing of , probably no significant change\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2123-01-18 00:00:00.000", "description": "Report", "row_id": 1324977, "text": "see carevue for details:\n\nNeuro: pt med on propofol, with sedation decreased able to move extrimities, to IR for angio pt placed on cistracarium gtt, titrated to effect, perla B/L nystagamus noted, vent drain increased to 20/tragus drg blood tinge fluid, current goal sys B/P < 160, ICP 10-12\n\nRESP: REMAINS INTUBATED ON SIMV SETTINGS, CONTINUES TO BE SX FOR THICK TAN SECRETIONS\n\nCV: SYS B/P MTN < SYS 160\n" }, { "category": "Nursing/other", "chartdate": "2123-01-18 00:00:00.000", "description": "Report", "row_id": 1324978, "text": "addedum:\n\nCV: IVF NS @ 80/HR, INFUSING VIA R FEM MULTI-LUMEN LINE,\nPNEUMO BOOTS ON L GROIN INSERTION SITE NO HEMATOMA NOTED,\nPERIPHERAL LINES PATENT.\n\nGI: NPO, BS HYPO-ACTIVE, SSI TITRATED\n\nGU: ADEQUATE HOURLY U/O\n\nA/P: CONTINUE EMOTIONAL SUPPORT AND MONITORING\n" }, { "category": "Nursing/other", "chartdate": "2123-01-19 00:00:00.000", "description": "Report", "row_id": 1324979, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per carevue. Lung sounds ess clear after suct mod th pale yellow sput. MDI given as per order. Pt in NARD on current settings; no vent changes required overnoc. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-19 00:00:00.000", "description": "Report", "row_id": 1324980, "text": "Condition Update\nPlease see carevue for specifics.\n\nNeuro: Pt is sedated on a ppf gtt. gtt titrated from 15mcg/kg to 30mcq/kg for pt comfort. On the gtt pt opened his eyes spontaneously, able to move all extremities on the bed, but was unable to follow any commands. Pt has a ventriculostomy drain at 20cm above tragus draining bloody fluid. ICP's . PERRl. Soft wrist restraints in place for pt safety.\n\nCV: Aline dampened. Using cuff on right arm for Bp's. Goal SBP <160's. SBP's 129-158 and received metoprolol 10mg x 1.\n\nGI/GU: Pt is NPO. NS with 20meq kcl infusing @ 60cc hour. OGT intact and to low continuous sxn draining bilious fluid. foley is patent and draining adequate amts of clear yellow urine.\n\nResp: Pt continues on SIMV +PS. No vent changes made overnight. LS are clear. 02 sats 100% Pt suctioned several times for moderate amts of thick yellow sputum.\n\nEndo: Pt has a sliding scale for BG control. No insulin required.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-19 00:00:00.000", "description": "Report", "row_id": 1324981, "text": "Respiratory Care\nPt extubated and placed on face tent. Strong congested cough, breath sounds coarse throughout. Not responsive to command.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-19 00:00:00.000", "description": "Report", "row_id": 1324982, "text": "Nursing note:\nNEURO: Waxes/wanes this afternoon. Lethargic at times and mildly agitated at others. , , lifts/holds w/all extremities. Follows simple commands inconsistently. Tongue midline. Vent drain dropped to 10cm above tragus from 20cm, ICP 4-9, draining blood-tinged CSF.\nRESP: Lung sounds coarse, dim to bases. Extubated w/o incident. Weak, non-productive cough. Post-extubation ABGs acceptable, sats 100% on 100% FT. Encouraged to cough and deep breathe w/little effect.\nCV: SR in 70s, no ectopy. Tmax 100.4. SBP 130s-140 on Labetolol gtt @ 2-3mg/min. Skin pale, warm and dry. Dopplerable pulses bilaterally. R. foot/hand cool but does have +pulses. Team aware.\nGI: Abdomen soft, +hypo BS. NPO. -stool.\nGU: Foley patent adequate amount amber urine.\nENDO: SSRI PRN, glucose levels stable.\nSOCIAL: Daughters and in to visit, updated by ICU fellow and Nsurg attending.\n\nA/P: Stable post extubation, slightly lethargic this afternoon w/waxing/ mental status. SBP w/in prescribed limits w/Labetolol gtt.\nContinue to monitor resp and neuro status, vent drain moved to 10cm above tragus. Aggressive pulm. hygeine, safety considerations. Continue current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-17 00:00:00.000", "description": "Report", "row_id": 1324972, "text": "admission note\npt arrived from mri. pt sedated for procedure and sbp in mri less than 140. o2 sat 99% on 100% fio2 with the vent.\nD: neuro: pt sedated. responds to painful stimuli. moves all extremities. does not follow commands. pupils are equal and reactive to light. vent drain at 10cm above the tragus. continues to drain blood tinged csf. icp 7-10. pt off all sedation but still sedated from large amt of ativan pt received in the er\n cardiac: pt started on nipride for sbp greater than 140. titrated up to .4mcg/kg/min. sbp 122/50.\ngi: ngt to lcws. positive bowel sounds. ngt continues to drain thick bilous drainage.\ngu: foley patent and draining clear yellow urine.\nresp: pt suctioned for thick brown sputum. bs remain coarse. left throacotomy incision well healed.\na: continue with q1hour neuro checks. titrate nipride as ordered.\nr: pt still sedated and neuro exam is unchanged. nipride currently at .4mcgs/kg/min. vent drain continues to drain blood tinged csf. suctioned for thick brown sputum. watch for temp spikes and treat and culture as needed.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-17 00:00:00.000", "description": "Report", "row_id": 1324973, "text": "Respiratory Care\nPt remains on mechanical ventilation. Taken to CT for head scan today and returned. No changes made to settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-17 00:00:00.000", "description": "Report", "row_id": 1324974, "text": "SEE CAREVUE FOR DETAILS:\n\nNEURO: PT HEAVILY SEDATED ON ATIVAN FROM EW, ON NIPRIDE GTT MTN SYS B/P 130-140'S, PT BECAME RESTLESS THIS PM PROPOFOL GTT STARTED. MOVES ALL EXTRIMITES WITH DECREASED SEDATION, PERLA 3MM'S, UNABLE TO FOLLOW COMMANDS VENT DRAIN 10 AT TRAGUS DRAINING BLOOD TINGE FLUID,ICP 8-10,\nDOWN FOR CT TODAY WITH AND WITHOUT CONTRAST\n\nRESP: S/P LEFT LOBECTOMY 1 MONTH AGO, INTUBATED CMV 650, PEEP 5, 40% O2, SX THICK TAN SECRETIONS BOTH ORALLY AND ETT, BS CLEAR B/L SAT 100%\n\nCV: T MAX 100.4, HR NSR, NIPRIDE AS STATED ABOVE, CSM +, IVF NS C 20 MEQ KCL @ 80 HR, PNEUMO BOOTS MTN RMULTI LUMEN FEM LINE, R A-LINE,\nAND PERIPHERAL LINES PATENT\n\nGI: OGT PATENT TO LCS DRAING BILLIOUS DRG, BS +, ABDOMEN SOFT, SSI TITRATED\n\nGU: ADEQUATE HOURLY U/O\n\nINT: HEAD DSG CLEAN DRY AND INTACT\n\nA/P: IR ANGIO IN AM, CONTINUE EMOTIONAL AND EDUCATIONAL SUPPORT TO FAMILY\n" }, { "category": "Nursing/other", "chartdate": "2123-01-18 00:00:00.000", "description": "Report", "row_id": 1324975, "text": "Resp Care Note:\n\nPt cont intub with OETT, sedated on mech vent as per Carevue. Lung sounds rhonchi clearing with suct for mod-lge amt th pale yellow sput. ABGs normalizing. MDI given as per order. Any intrinsic PEEP has resolved with MDI/decrease RR. Cont mech vent/ ?PSV today\n" }, { "category": "Nursing/other", "chartdate": "2123-01-18 00:00:00.000", "description": "Report", "row_id": 1324976, "text": "condtion update\nD: pt off propofol. opens eyes to name. follows commands. pupils equal and reactive to light. rotary nystagmus noted. pt seen by . icp remains . vent drain continues to drain cherry colored csf. lifts arms off bed. moves legs on bed and wiggles toes.\ncardiac: nipride weaned for sbp 130-140. pt currently on 3.0mcg/kg/min on nipride off propofol. nsr to st rate 90-105.\nresp: see flowsheet for abgs. pt suctioned for thick yellow sputum. bs are clear and diminshed at left base. rate decreased to 18 for abg at .\ngi: ngt continues to drain bilious fluid. abd soft and hypoactive bowel sounds.\ngu: urine output 20-100cc/hr. foley patent.\na: continue with neuro checks. titrate nipride as needed.\nr: pt more awake tonight. able to follow some commands. urine output borderline continue to monitor closely\n" }, { "category": "Nursing/other", "chartdate": "2123-01-22 00:00:00.000", "description": "Report", "row_id": 1324989, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\nNeuro: Pt alert this AM; sleepy in afternoon, but easily arousable by voice. Neuro exam q2hr. Oriented x2: to self and \"hospital.\" Follows commands. . Speech clear. +cough/+gag. Bilat wrist restraints d/t pt pulling at IV, foley, and nasal cannula. Bed alarm on.\nCV: Afebrile (Tmax 98.5). Hr 70-80s (NSR). Goal SBP <160. SBP overnoc 150-160s. This AM after metoprolol 10mg IV given, SBP decreased to 90-100s. Dr. (neurosurgery resident) and SICU team notified. Pt denies dizziness/lightheadedness. No interventions per HO; continue to monitor. Metoprolol held at 1600 d/t SBP<95. Hydralazine 10mg IV q6hr. DP/PT pulses palpable. No edema noted.\nPulm: Lung sounds CTA/diminished; O2 sat high 90s on 2LNC. + cough.\nGI: Abdomen softly distended w/ +bowel sounds. Pt tolerated fluids and jello; no dysphagia/no cough while drinking noted. Pt sat up at 90degree angle while eating/drinking. RISS q6hr.\nGU: Foley intact w/ clear yellow urine; uo qs.\nInteg: Skin W/D/I. Ecchymosis noted on bilat groin.\nActivity: Pt OOB to chair w/ 2 assists this AM. Pt w/ unsteady gait. Able to take few steps to chair. Back to bed when SBP 90s.\nSocial: wife and daughters in to visit today. RN discussed plan of care and transfer w/ family.\nPlan: Transfer to 5. Neuro exam as ordered by HO. Monitor VS, I's and O's, BS. Update family w/ plan of care and notify family w/ significant events.\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-17 00:00:00.000", "description": "Report", "row_id": 1324971, "text": "Resp Care Note:\n\nPt received from ER post ICB intub with OETT and placed on mech vent as per Carevue. Lung sounds ess clear; suct sm loose brn sput. ABGs iatrogenic resp alkalosis. Able to lower PIP with increase Ti slightly and together with MDI decrease intrinsic PEEP presently approximately 2cm (total PEEP 7cm). Also able to wean FIO2. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-21 00:00:00.000", "description": "Report", "row_id": 1324986, "text": "SICU NURSING PROGRESS NOTE 0700-1500\nNEURO--AWAKE,ALERT AND ORIENTED TO NAME AND FAMILY ONLY. WHEN ASKED ,\"WHERE ARE YOU,\" PT , \"I'M WITH THE ROACHES IN THIS DAMN HOTEL.\" MAE SPONT AND TO COMMAND. FOLLOWS COMMANDS CONSISTENTLY. SPEECH AND SWALLOW IN TO EVALUATE PT. HE IS OK TO EAT PUREED FOODS, LIQUIDS . HAVE PT CLEAR THROAT FIRST SEVERAL TIMES AFTER SWALLOWING.\nRECOGNIZES FAMILY, NOT DATE, TIME, SEASON, PRESIDENT. DOWN FOR HEAD CT. RESULTS PENDING. DILANTIN LEVEL ADDED ON. HEAD INCISION WITH DSD INTACT.\n\nCARDIAC--DEPENDING ON LEVEL OF AGITATION,SBP 140-160'S. HR80'S SR WITHOUT OBSERVED VEA. K+REPLETED.\n\nRESP--LUNGS WITH INSP/EXP WHEEZES IN UPPER LOBES BILATERALLY.WEANED O2 TO 50% FACE TENT. STRONG PRODUCTIVE COUGH BUT SWALLOWS SPUTUM. HAS NOT NEEDED TO BE NTS AT THIS TIME. SAO2 >96%.\n\nGI--ATE PUDDING,JELLO AND 240CC H2O WITHOUT DIFFICULTY. +BS. NO STOOL.\n\nGU--FOLEY CATH PATENT DRAINING >30 CC HR OF AMBER URINE.\n\nENDO--COVERED WITH SSRI 2U REG SQ.\n\nSKIN--INTACT,WITHOUT BREAKDOWN. HEAD INCISION WITH DSD.\n\nPAIN--DENIES PAIN.\n\nCOPING--WIFE AND DAUGHTER IN AT BEDSIDE. THEY HAVE BEEN UPDATED REGARDING PLAN OF CARE AND WOULD LIKE TO KNOW THE RESULTS OF THE CT SCAN.\n\nA--MS IMPROVING. PT . SPEECH AND SWALLOW CLEARED FOR PUREED FOOD.\n\nP--CON'T TO MONITOR. ASSESS NEURO STATUS.REDIRECT AND REORIENT. KEEP PT SAFE IN ENVIROMENT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-21 00:00:00.000", "description": "Report", "row_id": 1324987, "text": "SICU NURSING PROGRESS NOTE 0700-1500\nPT OOB TO CHAIR AT 1445 WITH ASSIST OF 2.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-22 00:00:00.000", "description": "Report", "row_id": 1324988, "text": "SICU NPN:\nS-\"I at the VA.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VITAL SIGNSL\n\nO-Neuro remain unchanged. Denies pain. Remains confused and restless. No Haldol given overnight. BPs remain uncontrolled at time secondary to restlessness and agitaion Lopressor and Hyrdralazine increased with fair affect. Goal BPs < 160. Foley patent with adequate hourly output. Urine clear and yellow in appearance. Tolerated thin liquid in upright postion. Otherwise night uneventful.\n\nA/P: s/p ICH doing better\nCall out to neuro SDU when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-20 00:00:00.000", "description": "Report", "row_id": 1324983, "text": "SEE CAREVUE FOR DETAILS:\n\nNEURO: PT AGITATED, RESTLESS, ATTEMPTING TO CLIMB OOB, MED X 3 WITH HALDOL WITH LITTLE EFFECT, CONFUSED,ABLE TO FOLLOW COMMANDS, AND MOVE ALL ,, VENT DRAIN 10/TRAGUS CONTINUES TO DRAIN BLOOD TINGE DRG, ICP 4-7\n\nRESP: 100% FACE TENT, ORALLY SX FOR THICK BLOOD TINGE TAN SECRETIONS ORALLY, NT SX FOR MINIMAL SECRETIONS, O2 SAT 100%, BS CLEAR AFTER SX, DIMINISHED AT BASES\n\nCV: A-LINE D/C DAMPENED, NON-FUNCTIONAL, LABETATOL D/C AT MN SYS B/P MTN 130-140, HR NSR, FEMORAL MULTI-LUMEN LINE PATENT, PERIPHERAL LINES D/C\n\nGI: BS HYPOACTIVE, ABDOMEN SOFT, NO FLATUS,NO BM\n\nGU: BORDERLINE U/ HOURLY, MD AWARE\n\nINT: VENT DSG STAINED WITH SCANT AMT OF SEROUS DRG\n\nA/P: ADDRESS NUTRITIONAL STATUS, MONITOR U/O CLOSLEY, CONTINUE EMOTIONAL SUPPORT WITH FAMILY\n" }, { "category": "Nursing/other", "chartdate": "2123-01-20 00:00:00.000", "description": "Report", "row_id": 1324984, "text": "Nursing note:\nNEURO: Neuro status continues to wax/wane. Agitated and restless at times, pulling at 02 , lines, etc; and then difficult to arouse at times. 3mm and brisk. MAE on bed, following simple commands. Answers simple questions appropriately, speech normal. Will consistently open eyes to voice. Pt. dislodged vent drain this am, head CT done showing no change at present. Will repeat unless pt. has acute neuro changes.\nRESP: Lung sounds very coarse throughout, FT 100% w/sats 99-100%. Drops sats to mid -80s when off 02. Sats in low 90s on 50%. Encouraged to cough/deep breathe w/little effect, CPT done frequently. Pt. has weak cough, does not raise any sputum. NT suctioned x1 for thick blood-tinged secretions, suctioning did produce a strong cough.\nCV: Afebrile. SR in 70s, no ectopy. SBP <140 on Labetolol gtt to be transitioned to PRN Lopressor IV. Skin pale, warm and dry. Palpable pulses.\nGI: Abdomen soft, non-tender. +BS. -Stool. NPO.\nGU: Foley patent adequate amount amber urine.\nENDO: Glucose levels stable.\nSKIN: Intact.\n\nA/P: Stable, slightly more lethargic today at times s/p vent drain removal. Continue to monitor resp, neuro status closely for change.\nAggressive CPT, head CT tomorrow unless decompensates.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-21 00:00:00.000", "description": "Report", "row_id": 1324985, "text": "SICU\nS-\"No.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VITAL SIGNS\n\nO-Neuro exam improving overnight. A/O/X/2. Still with periods of lethargy after periods of restlessness and agitation. No Haldol given overnight. Physicla neuro exam unchanged. Denies pain. HR 70-90s, NSR with no viewed ectopy. SBPs 120-150s, ocassionally in the 160s and 170s when agitated. Tolerating Lopressor IVP ATC well. Breaths sounds very rhoncerous with crackles intially depsite suctioning orally. Later NT suctioned with better results. Sats slightly down into the low 90s and increased to 70%. CXR and unchanged from previous. ABG wnls. Suctioned for thick rust colored blood tinged sputum in large to copious amounts. HUO down from previous shift. HUO 45-60cc/hr and concentrated in appearance. No fluid challenge of fluid given since coronary history. Dr. aware. Remain NPO. No NGT in place.\nPossible plans for doboff to be placed.\nA/P: s/p ICH\nRepeat CT Scan today\nPossible dobfhoff today\nContinue to pulmonary toilet aggressively\n" }, { "category": "Radiology", "chartdate": "2123-01-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 851518, "text": " 8:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: patient intubated, eval placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with above\n REASON FOR THIS EXAMINATION:\n patient intubated, eval placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient intubated. Check position of tubes.\n\n FINDINGS:\n\n A single AP supine chest image. The endotracheal tube is well positioned with\n its tip approximately 3 cm above the carina. The NG line is also in good\n position with its tip below the mid portion of the stomach. The lungs are not\n fully displayed and the right lateral chest is not demonstrated. There\n appears to be some ill-defined infiltrate at the right base laterally, not\n well shown. There is also evidence of some patchy atelectasis at the left\n base with slight elevation of the left hemidiaphragm. No other significant\n cardiopulmonary abnormality can be identified.\n\n IMPRESSION:\n\n Ill-defined infiltrate at the right base and some patchy atelectasis at the\n left base. No other significant cardiopulmonary abnormality. The\n endotracheal tube and NG line appear well positioned.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 851904, "text": " 4:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulmonary edema\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with significant fluid positive\n\n REASON FOR THIS EXAMINATION:\n r/o pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A 67-year-old male with positive fluid balance.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: .\n\n FINDINGS:\n\n The patient has been extubated. Cardiac and mediastinal contours are stable.\n There has been an interval increase in prominence of ill-defined parenchymal\n opacities within the left mid and lower lung zones. There is an increased\n retrocardiac density, likley atelectasis. A small left pleural effusion is\n present. There is no pneumothorax. Examination is limited by exclusion of\n the right chest wall.\n\n IMPRESSION:\n\n 1. Increased prominence of parenchymal opacities within the left mid and\n lower lung zone. This could represent asymmetric pulmonary edema or evolving\n infection.\n\n 2. Small left pleural effusion.\n\n 3. Left lower lobe atelectasis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2123-01-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 851526, "text": " 9:46 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ich\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with ich\n REASON FOR THIS EXAMINATION:\n ich\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SADk SAT 11:39 PM\n blood in both lateral ventricles,3rd, 4th. left to right midline shift.\n catheter in r lat/3rd ventricle\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: Intracranial hemorrhage.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is high attenuation, consistent with hemorrhage, in both\n lateral ventricles, the 3rd ventricle, and the 4th ventricle. There is mild\n left-to-right midline shift. A catheter is seen terminating in the region of\n the right lateral ventricle, 3rd ventricle junction. There is a tiny bubble\n of air seen in the right lateral ventricle and within the parenchyma of the\n left temporoparietal region. There are no subdural or epidural collections.\n The left lateral ventricle is larger than the right. The /white matter\n differentiation is preserved. No areas of major vascular territorial\n infarcts. There is mild mucosal thickening within the ethmoid air cells, but\n the remainder of the paranasal sinuses appear normal. No acute fractures.\n\n IMPRESSION\n 1. Intraventricular hemorrhage within both lateral ventricles, the 3rd\n ventricles, and the 4th ventricle. There is mild left-to-right midline shift.\n 2. The ventriculostomy catheter is seen at the right lateral ventricle, 3rd\n ventricle junction, with the left lateral ventricle larger than the right.\n 3. Early hydrocephalus. The ventricular catheter appears to be well\n positioned.\n\n" }, { "category": "Radiology", "chartdate": "2123-01-18 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 851689, "text": " 12:12 PM\n CAROT/CEREB Clip # \n Reason: r/o AVM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 248\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CERVICAL BILAT CAROTID/CEREBRAL UNILAT *\n * VERT/CAROTID A-GRAM EXT BILAT A-GRAM *\n * -52 REDUCED SERVICES C1769 GUID WIRES INFU/PERF *\n * C1769 GUID WIRES INFU/PERF C1769 GUID WIRES INFU/PERF *\n * C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with multiple intraventricular hemorrhage\n REASON FOR THIS EXAMINATION:\n r/o AVM\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Intraparenchymal and intraventricular hemorrhage.\n\n POSTOPERPATIVE DIAGNOSIS: Same, with subclavian steal syndrome, left carotid\n artery occlusion at the origin of the left common carotid artery and left\n subclavian stenosis.\n\n INDICATIONS: Mr. is a 67-year-old male with a history of\n intraventricular hemorrhage who presented after a recurrent intraventricular\n hemorrhage. He has a known history of peripheral vascular disease and\n undergoes this diagnostic angiogram to further evaluate an underlying cause\n for his intraventricular hemorrhage.\n\n CONSENT: The family was given a full and complete explanation of the\n procedure. Specifically, the indications, risks, benefits, and alternatives to\n the procedure were explained in detail. In addition, the possible\n complications, such as the risk of bleeding, infection, stroke, neurological\n deficit or deterioration, groin hematoma, and other unforeseen complications,\n including the risk of coma and even death, were outlined. The family\n understood and wished to proceed with the operation.\n\n ANESTHESIA: General endotracheal.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial blood, a 4 Fr vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: the right subclavian artery,\n right vertebral artery, right common carotid artery, right internal carotid\n artery, aorta, and left subclavian artery.\n\n (Over)\n\n 12:12 PM\n CAROT/CEREB Clip # \n Reason: r/o AVM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 248\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n RESULTS: Injection of the right subclavian artery demonstrates\n normal appearance of the vessel itself and a somewhat tortuous origin of the\n right vertebral artery. On injection of the right subclavian artery, contrast\n reflux is seen within the left subclavian artery and left vertebral artery on\n delayed arterial phase. Injection of the right vertebral artery demonstrates a\n smooth cervical course without evidence of stenosis or dissection.\n Intracranially, flow contribution is seen to the basilar artery and its\n branches and retrograde through the left vertebral artery. Furthermore, flow\n contribution is seen to the left MCA territory via a patent left posterior\n communicating artery. Within the posterior parietal- occipital lobe, multiple\n small fine pial-pial collateral vessels are seen which are likely the source\n of the patient's recurrent intraventricular hemorrhage. Otherwise, flow\n contribution is seen on injection of the right vertebral artery to the\n posterior cerebral arteries bilaterally. No evidence of intracranial aneurysm\n or stenosis is identified on these views. Injection of the right common\n carotid artery demonstrates a smooth cervical course without evidence of\n stenosis or dissection. The carotid bifurcation appears smooth without any\n evidence of atherosclerotic plaque. Injection of the right internal carotid\n artery demonstrates a normal cervical, petrous and intracranial course.\n Intracranially, flow contribution is seen to the MCA and ACA territories on\n the right as well as the anterior cerebral artery and the middle cerebral\n artery on the left via an anterior communicating artery. No evidence of\n intracranial aneurysm is present. Additionally, no other areas of intracranial\n stenosis or dissection are visualized. Injection of the left subclavian artery\n demonstrates a high-grade stenosis approximatly 2 cm from the origin of this\n vessel from the aorta. On injection of the left subclavian artery, no\n opacification of the left vertebral artery is appreciated. Visualization of\n the left vertebral artery is provided on contrast injection of the right\n vertebral artery. There appears to be a moderate-grade stenosis of the origin\n of the left vertebral artery. At this point, the 4 Fr diagnostic catheter was\n exchanged for a 4 Fr pigtail catheter. The pigtail catheter was postitioned\n within the ascending aorta and machine injection runs demonstrated a complete\n occlusion of the left common carotid artery at the origin from the aortic\n arch.\n\n IMPRESSION:\n 1. Subclavian steal syndrome secondary to a high-grade stenosis of the\n proximal origin of the left subclavian artery with contrast reflux through the\n left vertebral artery on injection of the right vertebral artery.\n 2. Moderate stenosis of the origin of the left vertebral artery.\n 3. Complete occlusion of the left common carotid artery at its origin.\n 4. Collateral flow to the MCA of the left via a patent posterior communicating\n and anterior communicating artery.\n 5. Multiple small pial-pial collateral vessels on the left, consistent with\n the patient's recurrent intraventricular hemorrhage.\n (Over)\n\n 12:12 PM\n CAROT/CEREB Clip # \n Reason: r/o AVM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 248\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2123-01-17 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 851534, "text": " 12:24 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n MRA BRAIN W/O CONTRAST\n Reason: lesion causing hemorrhage\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with intraventricular hemorrhage\n REASON FOR THIS EXAMINATION:\n lesion causing hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 67-year-old male with intraventricular hemorrhage.\n\n TECHNIQUE: MR of the brain without contrast. MR angiography of the circle of\n was also performed.\n\n COMPARISONS: This study is correlated with a CT performed on .\n\n FINDINGS: Again noted, is extensive intraventricular hemorrhage involving\n both lateral ventricles, the 3rd ventricle and the 4th ventricle. Again noted\n is a ventriculostomy catheter via right approach.\n\n There is minimal midline shift noted from left-to-right. No definite\n underlying vascular lesions are noted. Tiny areas of hyper-intensity is noted\n in the periventricular deep white matter, consistent with small vessel\n disease.\n\n MR total occlusion of the proximal left internal\n carotid artery. There is reconstitution of the left anterior and middle\n cerebral artery branches via the anterior communicating artery from the right\n side.\n\n IMPRESSION\n 1. Extensive intraventricular hemorrhage.\n 2. Minimal midline shift.\n 3. No abnormal vascularity noted to suggest AV malformation. However, a\n conventional angiogram is recommended for further evaluation.\n 4. Total occlusion of the left proximal internal carotid artery.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2123-01-17 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 851569, "text": " 11:31 AM\n CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: CTA, r/o aneurysm\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n CTA, r/o aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Intraventricular hemorrhage, ? aneurysm.\n\n CT angiogram of the intracranial circulation with multiplanar reformatted\n images and 3D reconstructed images.\n\n FINDINGS:\n\n NONCONTRAST HEAD CT:\n\n The degree of intraventricular hemorrhage is unchanged from exam of .\n The ventricles are more dilated than the previous exam. The ventricular\n catheter is in unchanged position.\n\n IMPRESSION: No change from previous exam, with stable intraventricular\n hemorrhage.\n\n CT ANGIOGRAM:\n\n FINDINGS: There is occlusion of the left internal carotid artery with\n reconstitution of the cavernous carotid by primarily the ophthalmic artery but\n also with contributions from the posterior communicating artery and possibly\n from the right side through the anterior cerebral artery. There is some\n irregularity of distal left middle cerebral artery branches attributable to\n either atherosclerosis or possibly vasospasm if there has been some\n subarachnoid hemorrhage. There is no definite evidence of aneurysm. The left\n A2 portion of the anterior cerebral artery is diminutive, relative to the\n right, perhaps related to some flow diversion into the left middle cerebral\n artery distribution.\n\n IMPRESSION: No evidence of aneurysm. Occluded left internal carotid artery.\n Collateral flow, as discussed above.\n\n" }, { "category": "Radiology", "chartdate": "2123-01-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 851733, "text": " 8:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?? CHF ??\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with significant fluid positive\n REASON FOR THIS EXAMINATION:\n ?? CHF ??\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Shortness of breath, evaluate for CHF.\n\n CHEST SUPINE: The heart does not appear significantly enlarged. No definite\n effusions are seen, and no radiographic evidence of failure is present.\n Subtle opacification in the right lower lobe laterally is present and a right\n lower lobe pneumonia may be present. Density is seen overlying the thoracic\n inlet, uncertain origin, not present on the prior chest x-ray and therefore is\n probably something lying outside of the chest itself. The endotracheal tube\n lies 6.6 cm from the carinal angle. The tip of the nasogastric tube is in the\n satisfactory position.\n\n IMPRESSION:\n\n Probable right lower lobe infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-01-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 852133, "text": " 9:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: change in hydrocephalus\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with intraventricular hemorrhage\n REASON FOR THIS EXAMINATION:\n change in hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67 y/o man with intraventricular hemorrhage. Assess for change in\n hydrocephalus.\n\n COMPARISON: Multiple head CT's the most recent dated .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Compared to prior exam, there is no change in the appearance of the\n ventricles or the ventricular hemorrhage involving the left lateral ventricle,\n third ventricle and fourth ventricle. Small area of intraparenchymal\n hemorrhage in the posterior aspect of the left corona radiata is also\n unchanged. The ventricular drain has been removed and there is a small\n residual amount of air in the frontal of the right lateral ventricle.\n There has been interval development of a thin rim of low attenuation subdural\n fluid which is likely related to the ventriculostomy drain removal.\n\n IMPRESSION: Unchanged appearance of intraventricular hemorrhage. No\n significant change in the size of the ventricles.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-01-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 852614, "text": " 8:58 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for resolution of blood products\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with intraventricular bleed on \n REASON FOR THIS EXAMINATION:\n Assess for resolution of blood products\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF EXAM: \n\n HISTORY: 67 year old with intracranial hemorrhage. Assess for resolution of\n blood products.\n\n COMPARISON: Multiple head CT's most recent dated .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Compared to prior exam there is residual but decreased amount of\n hemorrhage within the left lateral, third, and fourth ventricles. Small area\n of intraparenchymal hemorrhage in the posterior aspect of the left corona\n radiata is decreased in size. The ventricles are slightly less prominent.\n There has been interval resolution of the right frontal subdural fluid. The\n osseous and soft tissue structures are stable in appearance.\n\n IMPRESSION: Interval decrease in amount of ventricular blood and prominence\n of the ventricles. Decrease in size of left corona radiata intraparenchymal\n hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2123-01-25 00:00:00.000", "description": "P CHEST (SINGLE VIEW) PORT", "row_id": 852545, "text": " 2:34 PM\n CHEST (SINGLE VIEW) PORT Clip # \n Reason: ? pneumonia, decreased breath sounds, compare to prior\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with squamous cell lung ca s/p lobectomy 1 mo ago, ? pneumonia\n REASON FOR THIS EXAMINATION:\n ? pneumonia, decreased breath sounds, compare to prior\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreased breath sounds.\n\n PORTABLE CHEST: Comparison is made to prior study of .\n\n The cardiac and mediastinal contours are stable, allowing for patient\n rotation.\n\n There is still a sizeable infiltrate in the left base, which is either\n unchanged, or perhaps slighlty improved. There is a focal region of increased\n markings at the right base laterally, which is also without change. Blunting\n of the left lateral costophrenic angle is consistent with a small effusion,\n again without change. There is no evidence of a right effusion. No new\n pleuro-parenchymal abnormalities are identified.\n\n IMPRESSION: No significant change from five days earlier.\n\n" }, { "category": "Radiology", "chartdate": "2123-01-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 851998, "text": " 10:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: change in hydrocephalus\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with intraventricular hemorrhage\n REASON FOR THIS EXAMINATION:\n change in hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: This is a 67-year-old man S/P intraventricular\n hemorrhage assess for hydrocephalus.\n\n TECHNIQUE: Axial 5 mm sections of the brain were obtained without IV contrast\n and compared to the most recent prior non-contrast head CT dated .\n\n FINDINGS: When compared to the prior study of , there is no significant\n change in the ventricular size. The ventriculostomy tube has been removed from\n the right lateral ventricle and there is a small amount of air in the frontal\n of the right lateral ventricle. There remains a prominent amount of\n blood casting the left lateral ventricle, 3rd ventricle, and 4th ventricle.\n There is a small area of intraparenchymal hemorrhage in the posterior aspect\n of the left carona radiata which likely represents the source of the large\n intraventricular hemorrhage.\n\n IMPRESSION: No significant interval change in a prominent amount of\n intraventricular hemorrhage compared to . There has been no significant\n interval change in the size of the ventricles as well.\n\n" }, { "category": "Radiology", "chartdate": "2123-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 852082, "text": " 10:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with significant fluid positive, increasing oxygen\n requirement.\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 67-year-old man with significant fluid positive increasing\n oxygen requirement. Evaluate congestive heart failure.\n\n COMPARISON: Comparison is made with a prior AP view of the chest dated\n .\n\n SINGLE AP VIEW OF THE CHEST: The cardiac silhouette is somewhat enlarged.\n The mediastinal and hilar contours are normal. Pulmonary vasculature is\n mildly prominent, but stable when compared with the prior exam dated\n . There has been interval consolidation and opacification of the\n left lower lobe. Additionally, there is an increased in the left-sided\n pleural effusion. The right lung is clear. Surrounding soft tissues and\n osseous structures are stable.\n\n IMPRESSION:\n\n Interval worsening of the left lower lobe collapse and consolidation with new\n left pleural effusion consistent with a left lower lobe pneumonia.\n\n\n" }, { "category": "ECG", "chartdate": "2123-01-16 00:00:00.000", "description": "Report", "row_id": 267466, "text": "Sinus rhythm\nNormal ECG\nLeft ventricular hypertrophy by voltage\n\n" } ]

[ { "category": "Radiology", "chartdate": "2159-08-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1207534, "text": " 10:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dyspnea.\n\n COMPARISON: .\n\n PORTABLE UPRIGHT AP VIEW OF THE CHEST: The heart size remains moderately\n enlarged. The mediastinal contours are slightly widened. The aortic knob\n remains distinct with atherosclerotic calcifications. There is mild pulmonary\n edema which appears slightly worse when compared to the prior study. Small\n bilateral pleural effusions are noted, possibly increased from prior.\n Opacities in the lung bases likely reflect atelectasis. No pneumothorax is\n identified. Severe osteoarthritis is present within the glenohumeral joint on\n the right.\n\n IMPRESSION: Mild congestive heart failure which is slightly worse when\n compared to the prior exam.\n\n\n" }, { "category": "ECG", "chartdate": "2159-08-17 00:00:00.000", "description": "Report", "row_id": 107677, "text": "Sinus rhythm with a single uniform ventricular premature beats. Non-specific\nST-T wave abnormalities, although baseline artifact makes interpretation\ndifficult. Compared to the previous tracing of there is probably no\nsignificant change except for presence of ventricular ectopy.\n\n" }, { "category": "Radiology", "chartdate": "2159-08-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1208347, "text": " 2:05 PM\n CHEST (PA & LAT) Clip # \n Reason: interval change, worsening pulmonary edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with diastolic CHF with worsening ambulatory sats\n REASON FOR THIS EXAMINATION:\n interval change, worsening pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 84-year-old man with diastolic congestive heart failure\n with worsening ambulatory sats. Question of worsening edema.\n\n COMPARISON: and .\n\n In comparison to the film, the pulmonary edema has\n substantially decreased. There are post-surgical changes noted in the right\n lower and right mid lobe. There is bibasilar atelectasis. There is also a\n right-sided pleural effusion. Fifth rib is noted to have anterior defect,\n presumably from the patient's prior surgery.\n\n IMPRESSION: Overall, improving pulmonary edema.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2180-04-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1001356, "text": " 5:41 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with dry cough x week, palptiations, tachy to 120s\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, , AT 17:41 HOURS.\n\n HISTORY: Dry cough x1 week with palpitations and tachycardia.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Lung volumes are mildly diminished. No consolidation or edema is\n evident. The mediastinum is unremarkable. The cardiac silhouette is within\n normal limits for size. No effusion or pneumothorax is evident. The\n visualized osseous structures are unremarkable.\n\n IMPRESSION: No acute pulmonary process.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-04-08 00:00:00.000", "description": "Report", "row_id": 1672928, "text": "This is a 32 y old male with PMH of ETOH abuse (1-2 bottles of vodka qday). Pt sent to after mother stated she is afraid pt is going to drink himself to death. In EW, ETOH level was 327 and found to have alcoholic ketacidosis with BS in the 400's and AGap 0f 36. Pt given 5 liters of IVF and sent to MICU for further care. Pt has a 1:1 sitter after he told his parents that he wanted to kill himself.\n\nROS:\n\nNeuro) Pt is alert and oriented x 3. Pt is cooperative with care. 1:1 sitter at bedside for SI. Pt report he is not sure at this time if he wants to kill himself or not. Pt is on CIWA scale with prn valium for ETOH W/D. Pt reports feeling sl diaphoretic at times. Pt has mild hand tremors. Pt also had episodes of nausea, which was relievbed by zofran IV.\n\nID) urine culture sent and results pending. UA this am still + for ketones.\n\nCV) On arrival to MICU HR 120's, but decreased to SR (90's). EKG done and showed ST. BP stable as noted serum osmo 352 and IV hydration continued. Pt noted to be slight dizzy with amb to bed from stretcher. Phos 1.5 and replaced with good effect. FSBS NL and stable with Agap 21 this am. No edema noted. Please follow up electrolytes.\n\nResp) LS CTA w/o any SOB/DOE.\n\nGI) abd soft with + BS. Pt reports some tenderness to RLQ ( has been going on for a few years per PT). Pt had some episodes on nausea, which was treated well with zofran. No BM/V at this time. Pt on regular diet and with IV hydration.\n\nGU) Good U/O.\n\nSkin) skin intact.\n\nSoc) No contact from family members.\n\n\n" }, { "category": "ECG", "chartdate": "2180-04-07 00:00:00.000", "description": "Report", "row_id": 199351, "text": "Sinus tachycardia. There is a late transition which is probably normal.\nCompared to the previous tracing there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2180-04-07 00:00:00.000", "description": "Report", "row_id": 199352, "text": "Sinus tachycardia. Otherwise, normal tracing. Compared to the previous\ntracing of no diagnostic interim change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2108-05-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 870396, "text": " 11:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with s/p mvc w/ rt sided flaccid paralysis, +LOC\n REASON FOR THIS EXAMINATION:\n assess for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCT FRI 1:39 PM\n no acute intracranial hemorrhage or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48-year-old man status post MVC with right-sided flaccid paralysis\n and loss of consciousness.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, mass lesion,\n hydrocephalus, shift of normally midline structures, minor or major vascular\n territorial infarct. The density values of the brain parenchyma are within\n normal limits. Note is made of thickening and ground-glass opacities of the\n left frontal bone, extending along the posterior orbit and into the sphenoid.\n There is possible slight narrowing of the left optic foramen. There is slight\n opacification of the ethmoid air cells. Surrounding soft tissue structures\n are unremarkable.\n\n IMPRESSION:\n 1. No acute intracranial pathology including no sign of intracranial\n hemorrhage.\n 2. Left frontal/sphenoid fibrous dysplasia.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2108-05-11 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 870397, "text": " 11:54 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: assess for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with s/p mvc w/ rt sided flaccid paralysis, +LOC\n REASON FOR THIS EXAMINATION:\n assess for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCT FRI 2:52 PM\n multiple C3 and 4 fx. traumatic grade 1 anterolisthesis of c3 on 4 and locked\n right c3-4 facet. right c4 foramen transversarium fx.\n WET READ VERSION #1 JCT FRI 1:20 PM\n no acute intracranial hemorrhage or mass effect.\n WET READ VERSION #2 JCT FRI 1:38 PM\n multiple C3 and 4 fx. traumatic grade 1 anterolisthesis of c3 on 4. right c4\n foramen transversarium fx.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: 46-year-old man status post trauma.\n\n TECHNIQUE: Multidetector axial images of the cervical spine were performed\n without IV contrast. Coronal and sagittal reformatted images were obtained.\n\n FINDINGS: There is a comminuted fracture of C3 involving the lamina, spinous\n process, and both inferior facets. There is traumatic anterolisthesis of C3\n on C4 with perching of the right C3 facet on 4. At C4, there is wedge\n deformity of the vertebral body. There is a comminuted fracture of the right\n transverse process through the foramen transversarium. Fracture of the left\n superior articular facet is also noted. No other fractures or dislocations\n are identified. There are degenerative changes of the lower cervical spine\n from C4 through 7 with disc space narrowing and osteophytosis. CT is limited\n in its evaluation of intrathecal contents. The thecal sac is angulated at the\n C3-4 anterolisthesis, but the canal appears patent. There is prominent\n prevertebral soft tissue swelling.\n\n IMPRESSION:\n 1. Comminuted C3 fracture with traumatic rotational anterior subluxation of\n C3 on 4 with perching of the right C3 facet. Multiple posterior element and\n facet fractures.\n 2. Comminuted right C4 transverse process fracture extending into the foramen\n transversarium. Left C4 superior facet fracture. Possible wedge deformity of\n C4 vertebral body.\n\n" }, { "category": "Radiology", "chartdate": "2108-05-11 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 870415, "text": " 1:38 PM\n MR CERVICAL SPINE Clip # \n Reason: ASSESS FX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post trauma with cervical spine fracture, assess fracture.\n\n COMPARISON: CT of the cervical spine of same date.\n\n TECHNIQUE: Sagittal T1, T2, inversion recovery, and gradient echo images were\n obtained through the cervical spine. Additional axial T1 and T2-weighted\n images were obtained from C2-C3 through C7-T1.\n\n Axial T1 fat saturated images were obtained through the cervical spine.\n\n MRI OF THE CERVICAL SPINE: There is again seen malalignment of C3 on C4, with\n a perched right facet of C3 upon C4, unchanged from the CT of the cervical\n spine performed on the same date. There are comminuted fractures of C3 and\n C4, better demonstrated on the CT of the cervical spine. There is ligamentous\n disruption at the level of the comminuted C3 fracture, and Grade I anterior\n subluxation of C3 on C4. There is narrowing of the spinal canal at this level\n with cord compression, and abnormal T2 and STIR signal within the cord, highly\n suspicious for cord contusion.\n\n There is additional STIR hyperintensity within the paravertebral soft tissues\n about the fracture site, as well as within the posterior soft tissues of the\n neck.\n\n T1 fat saturated images obtained through the neck demonstrate hyperintensity\n adjacent to the right vertebral artery at the level of the fractures, which is\n very suspicious for a right vertebral artery dissection. In addition, there\n is a suggestion of hyperintensity on the fat saturated images about the left\n vertebral artery, a finding that is somewhat suspicious of a left vertebral\n artery dissection. There is no evidence of susceptibility artifact within the\n cord to suggest hemorrhage within the cord.\n\n IMPRESSION:\n 1. Comminuted fractures of C3 and C4, and anterior subluxation of C3 upon C4\n with a perched right C3 facet and narrowing of the spinal canal.\n 2. Cord compression at the level of C3-C4 with abnormal signal within the\n cord highly suspicious for cord contusion.\n 3. Abnormal signal on fat saturated images about the right and left vertebral\n arteries, very suspicious for right vertebral artery dissection and somewhat\n suspicious for left vertebral artery dissection. This finding could be\n confirmed with repeat imaging with T1 fat saturated images in several days.\n\n The suspicion for vertebral artery dissection was discussed with Dr. \n at approximately 4:30 p.m.\n\n\n\n (Over)\n\n 1:38 PM\n MR CERVICAL SPINE Clip # \n Reason: ASSESS FX\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2108-05-11 00:00:00.000", "description": "O C-SPINE NON-TRAUMA 2-3 VIEWS IN O.R.", "row_id": 870460, "text": " 6:23 PM\n C-SPINE NON-TRAUMA VIEWS IN O.R. Clip # \n Reason: SPINE FX NOW ORIF\n Admitting Diagnosis: SPINAL CORD INJURY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Spine fracture. ORIF.\n\n CERVICAL SPINE: Three lateral radiographs are submitted for interpretation.\n An endotracheal tube is present. In the initial radiograph, a surgical\n instrument localizes the C3-4 interspace. In subsequent radiographs, spacers\n have been placed at C3-4 and C4-5, and an anterior stabilization plate and\n screws traverse C3 through C5. There is straightening of the visualized\n cervical spine. Degenerative changes are noted at C5-6. The C6 and C7\n vertebral bodies are not visible.\n\n IMPRESSION: Operative changes, as above.\n\n" }, { "category": "Radiology", "chartdate": "2108-05-11 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 870401, "text": " 12:12 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: assess aorta & T,L,S spine\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with s/p mvc\n REASON FOR THIS EXAMINATION:\n assess aorta & T,L,S spine\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm FRI 1:14 PM\n No evidence of traumatic injury.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old man in a motor vehicle accident.\n\n TECHNIQUE: Contiguous axial CT images of the chest, abdomen, and pelvis were\n obtained. Multiplanar reconstructions were performed to better evaluate the\n anatomy and pathology.\n\n CONTRAST. 100 cc of IV Optiray was administered.\n\n CT OF THE CHEST WITH IV CONTRAST:\n\n The soft tissue window images reveal no significant axillary, mediastinal, or\n hilar lymphadenopathy. The heart, pericardium and the great vessels are\n unremarkable. There are no pleural or pericardial effusions.\n\n The lung window images reveal atelectasis at the right lung base. There are\n no lung nodules or areas of consolidation. The airways appear patent to the\n level of segmental bronchi bilaterally.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The aorta, liver, spleen, pancreas,\n adrenals, gallbladder, kidneys, and the ureters are unremarkable. The\n abdominal loops of small and large bowel appear normal. There is no\n mesenteric or retroperitoneal lymphadenopathy. There is no free air or free\n fluid.\n\n CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder, distal ureters,\n prostate, seminal vesicles, and the pelvic loops of small and large bowel\n appear unremarkable. There is no free air or free fluid.\n\n There are no suspicious lytic or blastic lesions of the osseous structures. A\n posterior fusion defect is seen in the sacrum.\n\n Multiplanar reconstructions confirm the above findings.\n\n IMPRESSION: Right lung base atelectasis. No evidence of traumatic injury.\n (Over)\n\n 12:12 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: assess aorta & T,L,S spine\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2108-05-11 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 870402, "text": " 12:13 PM\n CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: assess for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with s/p mvc\n REASON FOR THIS EXAMINATION:\n assess for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCT FRI 2:51 PM\n no t-spine fracture.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old man status post trauma.\n\n TECHNIQUE: Axial non-contrast multidetector scanning of the thoracic spine\n was performed. Sagittal and coronal reconstructions were obtained.\n\n FINDINGS: No disc, vertebral, or paraspinal abnormality is seen. There is no\n sign of a fracture or abnormal alignment of the component vertebrae. The\n visualized outline of the thecal sac appears unremarkable. Note is made of\n dependent atelectasis.\n\n IMPRESSION: Normal thoracic spine CT.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-05-11 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 870404, "text": " 12:13 PM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: assess for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with s/p mvc\n REASON FOR THIS EXAMINATION:\n assess for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg FRI 1:28 PM\n Bilateral spondylolysis of L5, with sclerotic margins suggesting chronic\n process. No acute fracture identified.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post trauma, evaluate for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial MDCT images were obtained through the lumbar spine without\n intravenous contrast. Additional coronal and sagittal reformatted images are\n provided.\n\n CT OF THE LUMBAR SPINE WITHOUT IV CONTRAST: There is bilateral spondylolysis\n at L5, with sclerotic margins consistent with a chronic process. No acute\n fracture is identified within the lumbar spine. There is degenerative change\n within the component vertebrae, including Schmorl's nodes within the inferior\n end plate of L1, and within the superior and inferior end plates of L2 and the\n superior end plate of L3. The intervertebral disc space heights are\n preserved. There is no evidence of spinal stenosis. The visualized outlines\n of the thecal sac appear unremarkable.\n\n IMPRESSION: Bilateral spondylolysis at L5, with features suggestive of a\n chronic process. No acute fracture identified within the lumbar spine.\n\n This finding was communicated to the Emergency Department dashboard by wet\n read at the time of image acquisition, approximately 1:45 p.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-05-11 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 870406, "text": " 12:46 PM\n CTA HEAD W&W/O C & RECONS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n CTA NECK W&W/OC & RECONS; -59 DISTINCT PROCEDURAL SERVICE\n CT 100CC NON IONIC CONTRAST\n Reason: assess for arterial inj\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with c3,4 fx\n REASON FOR THIS EXAMINATION:\n assess for arterial inj\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCT FRI 2:54 PM\n focal right vertebral artery dissection with intraluminal thrombus at c3-4\n levels.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: 46-year-old man with C3 and C4 fracture, assess vertebral injury.\n\n TECHNIQUE: 1.25 mm axial cuts were obtained throughout the neck, sagittal and\n coronal reconstructions were subsequently performed.\n\n FINDINGS: This is a preliminary on the CT angiogram since snaps shots\n are still not provided.\n\n There is asymmetric caliber along the vertebral arteries from the level of C2\n vertebral artery to approximately C5-C6 level. The right vertebral artery is\n smaller in diameter and is irregular at the level of C2-C3 and C3-C4 with a\n low-density center suggesting the presence of dissection and mural thrombus.\n The left vertebral artery is normal in caliber and with normal contrast\n density. Common carotid arteries, internal, and external carotid arteries\n appear unremarkable.\n\n There is subluxation of C2 over C3. There is loss of a disc space at the\n level of C2-C3 and multiple fractures are present throughout the cervical\n spine, please see report of the cervical spine for further findings.\n\n As an incidental finding, there is well-circumscribed lucent lesions seen\n involving the left frontal skull and extending to the clivus, which have more\n ?? sclerotic ?? appearance consistent with fibrodysplasia.\n\n INTERPRETATION: Asymmetry and irregularity of the right vertebral artery at\n the level of C2-C3 and C3-C4 consistent with vertebral dissection and mural\n thrombus. Complete report to follow when snap shots are given.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2108-05-11 00:00:00.000", "description": "Report", "row_id": 1359885, "text": "T/SICU RN Admit/Progress Note\nPt is a 46 yo male involved in at MVC where he was stopped at a red light, and was rearended by a car traveling at a greater speed than 50mph. Pt was propelled into a wall. Unrestrained, ?LOC, does not remember accident. At scene c/o inability to move R side. Transported to hospital, then to . CT and MRI at showed C 3-4-5 fx with vertebral body fx, and a L neck dissection. Transferred to T/SICU for further care.\n\nCurrent ROS\nNeuro: Alert and oriented, pleasant. L side able to move all extremities with good strength. R side + sensation, slight tingling in R arm. Able to wiggle R toes and slightly move R leg on bed. Able to move R shoulder but no movement with R fingers. Solumedrol gtt started at 12 noon by ED (bolus was given at hospital), to continue for 23hrs. Fentanyl IVP prn for pain with effect\n\nCV: HR 60-70's SR no ectopy. NBP 120-140's systolic. IVF @75cc/hr.\n\nResp: Lungs clear strong cough, Sats 97-99% on 2ln/c RR 20's\n\nGU/GI: NPO, pepcid, abd soft +bowel sounds. Foley with clear yellow urine.\n\nEndo: Blood glucose 142 no coverage needed per RISS.\n\nSkin/Mobility: Logroll, c-collar on at all times. Skin grossly intact, no breakdown noted.\n\nSocial: Wife, sons, and other family in updated by MD and RN, support given.\n\nA: s/p MVC with C3-4-5 fx and R sided weakness/deficits.\n\nPlan: To OR at 1830 for decompression on C3-4-5 with Dr. .\n" }, { "category": "Nursing/other", "chartdate": "2108-05-11 00:00:00.000", "description": "Report", "row_id": 1359884, "text": "Social Work\nSW met with family briefly before taking them to pt's room. Pt reportedly was asking for his family. SW met with pt's wife and sister, introducing SW and our role in pt's care. SW obtained contact info for wife, , as well: (H) and (C). SW will continue to follow on Monday. Weekend SW available for page if needed.\n" }, { "category": "Radiology", "chartdate": "2108-05-11 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 870395, "text": " 11:38 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: MVA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Trauma.\n\n AP CHEST: There is apparent widening of the upper mediastinum, a finding that\n may reflect the portable nature and supine technique of this radiograph. No\n effusion, pneumothorax, fractures, or pleural effusion are seen.\n\n AP PELVIS: This examination is limited by the overlying trauma board. No\n evidence of fracture, dislocation, bone destruction, bone erosion, or\n radiopaque foreign bodies.\n\n IMPRESSION: Apparent widening of the upper mediastinum, a finding, which may\n represent the supine portable technique. A CT of the chest with contrast\n should be performed if there is clinical suspicion for aortic injury.\n\n" }, { "category": "Radiology", "chartdate": "2108-05-13 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 870632, "text": " 5:22 PM\n MR CERVICAL SPINE Clip # \n Reason: r/o persistent stenosis\n Admitting Diagnosis: SPINAL CORD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with c3-4 fracture / dislocation\n REASON FOR THIS EXAMINATION:\n r/o persistent stenosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: C3-4 fracture/dislocation, rule out persistent stenosis.\n\n TECHNIQUE: Imaging performed at 1.5 Tesla. Sequences include sagittal T1,\n T2, and STIR and axial T2 STIR weighted and T2 images through the cervical\n spine.\n\n C-SPINE MRI WITHOUT CONTRAST:\n\n The patient is status post fusion procedure with anterior plate and screws\n extending from C3 through C5. Susceptibility artifact obscures some of the\n surrounding bone and soft tissue anatomy. There is probably very mild convex\n curvature centered at the C3/4 level. There is considerable edema in the\n prevertebral soft tissues and the soft tissues posterior to the upper spine.\n Of note, there is abnormal elevated T2 signal throughout much of the cord,\n most pronounced at the level of C3/4, where there is suggestion of very slight\n expansion of the cord. This appears qualitatively somewhat more intense than\n that seen on , though direct comparison of signal intensity in this way\n is not quantitative.\n\n At C2/3, the central canal and neural foramina are patent. There is soft\n tissue edema, including some soft tissue signal in the region of the left\n neural foramen.\n\n At C3/4, there is mild-to-moderate central canal narrowing reflecting\n vertebral body alignment and probably congenital narrowing of the canal. This\n is slightly more prominent inferolaterally in the left paramedian area, where\n there is effacement of almost all of the anterior CSF space and some of the\n posterior CSF space. The right neural foramen is patent. There is probably\n mild-to-moderate narrowing of the left neural foramen, not optimally\n demonstrated due to patient motion. Slight expansion of the cord at this\n level is noted.\n\n At C4/5, there is mild-to-moderate central canal stenosis reflecting alignment\n and developmentally short canal. The neural foramina are not well delineated\n due to soft tissue edema. There is possible minimal right neural foraminal\n narrowing and suspected moderate left neural foraminal narrowing.\n\n At C5/6, there is moderately severe to severe central canal narrowing\n reflecting developmental stenosis, a small to moderate diffuse disc osteophyte\n complex. There is effacement of all of the CSF about the cord (series 18,\n image 269), with slight deformation of the cord. The disc osteophyte complex\n is most prominent in the left paramedian position. There may be mild neural\n (Over)\n\n 5:22 PM\n MR CERVICAL SPINE Clip # \n Reason: r/o persistent stenosis\n Admitting Diagnosis: SPINAL CORD INJURY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n foraminal narrowing.\n\n At C6/7, there is a small diffuse disc osteophyte complex causing moderate to\n moderately severe central canal stenosis with effacement of much of the CSF\n about the canal (series 18, image 272). The neural foramina are grossly\n patent.\n\n At C7/T1, no spondylotic ridging. Neural foramina and central canal are\n patent.\n\n There is low signal of the CSF on the T2-weighted images. I suspect this is\n pulsation artifact, though the presence of a small amount of hemorrhage within\n the cord cannot be excluded. No obvious epidural collection is identified.\n\n IMPRESSION:\n 1. Status post anterior fusion procedure, with extensive soft tissue edema\n both posterior and anterior to the spinal canal.\n\n 2. Abnormal elevated T2 signal within the cord, most pronounced at C3/4,\n where there is slight expansion of the cord due to the internal edema and/or\n hemorrhage. Of note, there is no high T1 signal to confirm the presence of\n hemorrhage.\n\n 3. Multilevel neural foraminal narrowing as described, most pronounced at C5/6\n and C6/7 due to combination of osteophytic ridge and small central canal. More\n moderate stenosis at the level of C3/4 and C4/5 as described.\n\n 4. Due to presence of considerable motion artifact, vascular structures cannot\n be evaluated.\n\n" }, { "category": "Radiology", "chartdate": "2108-05-14 00:00:00.000", "description": "NON-IONIC LESS THAN 100CC", "row_id": 870660, "text": " 7:18 AM\n IVC GRAM/FILTER Clip # \n Reason: filter\n Admitting Diagnosis: SPINAL CORD INJURY\n Contrast: OPTIRAY Amt: 35\n ********************************* CPT Codes ********************************\n * INTERUP IVC INTRO CATH SVC/IVC *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n * C1880 VENA CAVA FILTER NON-IONIC LESS THAN 100CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with\n REASON FOR THIS EXAMINATION:\n filter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old male with spinal cord injury and need for\n prophylactic IVC filter placement.\n\n PROCEDURE: The procedure was performed by Dr. , Dr. \n , and Dr. . Dr. , the staff radiologist, was\n present and supervising throughout. After the risks and benefits of the\n procedure were discussed with the patient and informed consent was obtained,\n the patient was placed supine on the angiography table. His right groin was\n prepped and draped in the standard sterile fashion. Through an anesthetized\n skin approach and with the assistance of fluoroscopy, the right common femoral\n vein was accessed in the antegrade fashion with a 19-gauge single wall\n puncture needle. After venous blood was aspirated, a 0.035 wire was\n advanced through the access needle into the inferior vena cava under\n fluoroscopic visualization. The skin entry site was incised with a #11 blade\n scalpel. The access needle was replaced over the wire with a 6-French\n angiographic dilator. The 9-French Bard Recovery delivery sheath was then\n advanced over the wire into the right common iliac vein. After the\n wire was removed, a cavogram was performed via injection of nonionic\n contrast.\n\n The recovery delivery sheath was then advanced over the wire to the\n inferior endplate of the L1 vertebral body. Following the removal of the\n wire along with the inner dilator, the Bard Recovery Nitinol Filter\n was successfully deployed under direct fluoroscopic visualization with the\n apex of the filter positioned at the level of the insertion of the right renal\n vein (the lower of the two renal veins). A fluoroscopic spot film of the\n abdomen was then obtained, documenting filter position. The 9-French recovery\n delivery sheath was then removed from the right common femoral vein and manual\n pressure was held at the venous puncture site until hemostasis was achieved. A\n dry sterile dressing was applied.\n\n FINDINGS: A cavogram revealed a single and widely patent inferior vena cava\n with the insertion of the left renal vein at the mid T12 vertebral body level\n and the insertion of the right renal vein at the level of the mid L1 vertebral\n body. A fluoroscopic spot film of the abdomen demonstrated the filter apex to\n be at the level of the mid L1 vertebral body.\n (Over)\n\n 7:18 AM\n IVC GRAM/FILTER Clip # \n Reason: filter\n Admitting Diagnosis: SPINAL CORD INJURY\n Contrast: OPTIRAY Amt: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MEDICATIONS: 1% lidocaine. 0.5 mg of Versed and 25 mcg of fentanyl were\n administered in intermittent doses with continuous monitoring of vital signs\n by the nursing staff.\n\n CONTRAST: 35 cc of full-strength Optiray 320.\n\n COMPLICATIONS: None.\n\n IMPRESSION:\n 1. Cavogram revealed a single and widely patent IVC without evidence of\n thrombus.\n\n 2. Successful placement of a retrievable Bard Recovery Nitinol IVC Filter\n with the filter apex in an infrarenal position.\n\n This filter may be left in permanently or may be retrieved at any time.\n\n\n" }, { "category": "Radiology", "chartdate": "2108-05-14 00:00:00.000", "description": "O C-SPINE NON-TRAUMA 2-3 VIEWS IN O.R.", "row_id": 870739, "text": " 4:33 PM\n C-SPINE NON-TRAUMA VIEWS IN O.R. Clip # \n Reason: CERVICAL FUSION\n Admitting Diagnosis: SPINAL CORD INJURY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cervical fusion.\n\n TECHNIQUE: Two lateral radiographs of the neck were performed\n intraoperatively without radiologist present. Image demonstrate localization\n of the C4 vertebral body, with anterior fixation plate. For additional\n details, please consult the operative note.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2129-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1192986, "text": " 5:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman critically ill with cardiogenic shock, possible\n pheochromocytoma, still intubated, now with persistent fevers\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n INDICATION: Cardiogenic shock, intubation, persistent fevers.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing left lower\n lobe opacity is unchanged in extent and morphology. This substantiates the\n possibility for left basal pneumonia. Otherwise, the radiograph is also\n unchanged, unchanged size of the cardiac silhouette. No other parenchymal\n opacities, the monitoring and support devices are constant.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1193950, "text": " 9:18 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please eval PICC line and HD catheter placement\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with suspected pheochromocytoma and renal failure on CVVH\n REASON FOR THIS EXAMINATION:\n Please eval PICC line and HD catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:27 \n\n HISTORY: Suspected pheochromocytoma. Renal failure. PICC line.\n\n IMPRESSION: AP chest compared to through 13:\n\n Moderately severe pulmonary edema, a longstanding left lower lobe atelectasis\n and small bilateral pleural effusions have increased minimally since ,\n stable without change since . Tip of the new left PIC line in the mid\n SVC, alongside a new right supraclavicular central venous dual-channel\n dialysis catheter that ends in the upper right atrium and low SVC. Heart is\n normal size. No pneumothorax or mediastinal widening.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1193477, "text": " 7:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change?\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with intubated and chest tube\n REASON FOR THIS EXAMINATION:\n ? interval change?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 44-year-old woman with intubation and chest tube placement.\n Evaluate for interval change.\n\n FINDINGS: Comparison is made to the previous study from .\n\n The central venous catheter, endotracheal tube, and feeding tube are unchanged\n in position. There is again seen a left retrocardiac opacity and bilateral\n pleural effusions as well as the pulmonary interstitial prominence which are\n all stable since the prior study. No pneumothoraces are seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1193152, "text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval progression\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with hypoxemic respiratory failure\n REASON FOR THIS EXAMINATION:\n Interval progression\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old female with hypoxic respiratory failure.\n\n COMPARISON: .\n\n PORTABLE CHEST: In comparison to study performed one day prior, there is\n little interval change. A left IJ catheter again extends to the SVC. There\n is a left apical chest tube, with no appreciable residual pneumothorax. There\n is persistent left basilar retrocardiac opacity, with air-bronchograms, again\n concerning for pneumonia in the appropriate clinical setting, though a similar\n appearance could result from atelectasis or aspiration. There is no new\n recent parenchymal opacity. Heart size is unchanged. There is no large\n effusion. No acute osseous abnormalities or free air is seen in the\n hemidiaphragm.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1193114, "text": " 9:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Interval progression\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with hypoxemic respiratory failure\n REASON FOR THIS EXAMINATION:\n Interval progression\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxemic respiratory failure.\n\n FINDINGS:\n\n In comparison with the earlier study of this date, there is no appreciable\n change. Continued opacification at the left base could again reflect\n atelectasis or pneumonia. Monitoring and support devices are stable.\n Indistinctness of pulmonary vessels suggests some elevation of pulmonary\n venous pressure.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1193542, "text": " 3:52 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Interval change\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman s/p extubation\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 44-year-old woman status post extubation. Evaluate for\n interval change.\n\n FINDINGS: Comparison is made to prior study from .\n\n There has been removal of endotracheal tube as well as the feeding tube.\n There remains a left-sided intravenous catheter with distal lead tip in the\n mid SVC. Cardiac silhouette is unchanged. There is also unchanged left\n retrocardiac opacity and increased density at the lung bases as well as some\n prominence of pulmonary interstitial markings, stable. No pneumothoraces are\n present.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1193597, "text": " 7:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval progression\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with hypoxemic respiratory failure\n REASON FOR THIS EXAMINATION:\n Interval progression\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:45 .\n\n HISTORY: Hypoxic respiratory failure.\n\n IMPRESSION: AP chest compared to through , 4:03 p.m.:\n\n The pulmonary edema has worsened, with greater coalescence of opacification in\n both lower lungs, particularly the left. This could be atelectasis, but\n pneumonia cannot be excluded. Moderate bilateral pleural effusions persist.\n Heart size is normal. Mediastinal vascular caliber is only mildly enlarged\n and unchanged. Dual-channel left supraclavicular central venous line ends\n centrally. Dr. was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1193297, "text": " 9:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? Bleed. Signs of anoxic brain injury\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with multiorgan failure and unresponsiveness off sedation\n REASON FOR THIS EXAMINATION:\n ? Bleed. Signs of anoxic brain injury\n CONTRAINDICATIONS for IV CONTRAST:\n allergy\n ______________________________________________________________________________\n WET READ: LLTc SAT 12:04 AM\n No acute intracranial process. Specifically, there is no evidence of bleed or\n hypoxic injury. MRI can be considered as a more sensitive test for early\n anoxic injury.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old female with multiorgan failure and unresponsiveness.\n\n No comparison studies available.\n\n TECHNIQUE: MDCT-acquired axial images of the head were obtained without the\n use of IV contrast.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass,\n mass effect, or large vascular territorial infarction. The ventricles and\n sulci are normal in configuration and size. There is no shift of normally\n midline structures. There is mild mucosal thickening within the right\n maxillary sinus (2:1). The remaining included views of the paranasal sinuses,\n mastoid air cells, and middle ear cavities are clear.\n\n IMPRESSION: No acute intracranial process. Specifically, there is no\n evidence of bleed or hypoxic injury. MRI can be considered as a more\n sensitive test for early anoxic injury.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1194795, "text": " 11:27 AM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for pleural effusions/infection\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with pheochromocytoma and on HD, complains of new cough\n this AM, diminished bs at bases\n REASON FOR THIS EXAMINATION:\n Please eval for pleural effusions/infection\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: 44-year-old woman with pheochromocytoma, on hemodialysis. New cough\n and decreased breath sounds at the bases.\n\n IMPRESSION: Minimal pulmonary edema has substantially improved over the past\n several days. Accompanying small bilateral pleural effusions probably smaller\n as well. Heart size top normal. Dual-channel right supraclavicular central\n venous dialysis catheter ends in the SVC, alongside left PIC line, and in the\n upper right atrium. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-14 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1193345, "text": " 9:05 AM\n PORTABLE ABDOMEN Clip # \n Reason: evidence of obstruction or ileus?\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with ?pheo, intubated, s/p cardiogenic shock, no BM x 1wk\n REASON FOR THIS EXAMINATION:\n evidence of obstruction or ileus?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable abdomen, .\n\n CLINICAL HISTORY: 44-year-old woman with possible cardiogenic shock.\n Evaluate for obstruction as the patient has had no bowel movement for one\n week.\n\n FINDINGS: There is a non-specific bowel gas pattern. There is air and stool\n seen throughout non-dilated loops of colon and small bowel. Air and stool are\n seen within the rectum. Bony structures are intact. There is a nasogastric\n tube whose tip and side port are below the gastroesophageal junction. No\n large amount of free air seen on this supine view.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-17 00:00:00.000", "description": "RENAL U.S.", "row_id": 1193898, "text": " 3:34 PM\n RENAL U.S.; DUPLEX DOPP ABD/PEL Clip # \n Reason: Please perform renal ultrasound w/ dopplers, want to be cert\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with suspected pheochromocytoma and ? retroperitoneal bleed\n seen on MRI after cath on , in on CVVH\n REASON FOR THIS EXAMINATION:\n Please perform renal ultrasound w/ dopplers, want to be certain RP bleed is not\n obstructing renal blood flow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old woman with suspected pheochromocytoma and\n retroperitoneal bleed. Please assess kidneys, specifically whether renal\n blood flow is obstructed.\n\n TECHNIQUE:\n Grayscale and Doppler ultrasound images of the kidneys were obtained.\n\n COMPARISON: Abdominal ultrasound from ; CT of the abdomen from\n .\n\n FINDINGS:\n Echogenic bilateral renal cortices suggests diffuse parenchymal renal disease.\n\n Limited renal doppler exam.\n\n The right kidney measures 13.5 cm, the left kidney measures 13 cm without\n evidence of hydronephrosis, stones, or masses. There is a known 5 x 3.9 x 3.5\n cm vascular mass superior to the right kidney, representing the known\n pheochromocytoma.\n\n The main renal artery, upper, mid, and lower pole RIs are slightly increased\n measuring between 0.75 and 0.79 on the right and between 0.75 and 0.84 on the\n left kidneys.\n\n The main renal veins are patent bilaterally.\n\n IMPRESSION:\n 1. Echogenic renal cortices suggesting parenchymal renal disease.\n 2. No hydronephrosis.\n 3. Normal renal flow bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1195159, "text": " 7:25 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Rule out PTX, confirm line placement, assess known pleural e\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with new left IJ insertion, rule out PTX\n REASON FOR THIS EXAMINATION:\n Rule out PTX, confirm line placement, assess known pleural effusion\n ______________________________________________________________________________\n WET READ: LLTc WED 8:48 PM\n Left IJ terminating at the junction of the left subclavian/axillary veins. No\n pneumothora. ET tube 4.1 cm above the carina. OG tube within the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New left IJ insertion, to assess for pneumothorax.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n left IJ catheter that turns distally so that the tip lies in the region of the\n junction of the left subclavian and axillary veins. No evidence of\n pneumothorax. Endotracheal tube tip lies approximately 4 cm above the carina\n and nasogastric tube extends to the stomach.\n\n This information was related to the doctor caring for the patient by the\n resident on call at 8:40 on .\n\n" }, { "category": "Radiology", "chartdate": "2129-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1193346, "text": " 9:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with intubation and chest tube\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 44-year-old woman with intubation and chest tube placement.\n\n FINDINGS: Comparison is made to the prior study from .\n\n There is a left-sided chest tube with distal pigtail within the left apex. No\n pneumothorax is seen. There is a left-sided central venous catheter with the\n distal lead tip in the mid SVC. Endotracheal tube tip is 5 cm above the\n carina, appropriately sited. There is a nasogastric tube whose tip and side\n port are below the gastroesophageal junction. There is prominence of the\n pulmonary vascular markings most confluent at the lung bases which have\n increased since the previous study.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1195243, "text": " 9:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval position of PICC after IJ line pull\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with recent line pull.\n REASON FOR THIS EXAMINATION:\n Please eval position of PICC after IJ line pull\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:39 AM, \n\n HISTORY: Line pulled. Evaluate change in PIC position.\n\n IMPRESSION: AP chest compared to , 7:27 p.m.:\n\n Dual-channel right supraclavicular central venous infusion set has been\n withdrawn minimally to the low SVC, without disturbing the left PICC line that\n ends at the level of the proximal infusion port, in the low SVC. Left lower\n lobe atelectasis has improved. Substantial right pleural effusion might be\n smaller, and small left pleural effusion is essentially unchanged. Heart size\n normal. No pneumothorax or mediastinal widening.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1193368, "text": " 11:35 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with hypoxic respiratory failure, presumed pheochromocytoma,\n concern for aspiration event vs flash pulmonary edema this AM, now w/ O2 sats\n of 90% (was 100% overnight)\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 44-year-old woman with respiratory failure and presumed\n pheochromocytoma. Concern for aspiration.\n\n FINDINGS: Comparison is made to the prior study from .\n\n There is a left-sided pigtail catheter within the left lung apex. No\n pneumothoraces are identified. There is an endotracheal tube, nasogastric\n tube, and right IJ central venous line, which are unchanged in position and\n appropriately sited. There is prominence of the pulmonary interstitial\n markings with more confluent areas of density at the lung bases. Overall,\n this is unchanged since the prior study from two and a half hours earlier.\n The heart size is normal.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-17 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1193910, "text": " 4:31 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line. She has anaphylactic reaction to iod\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with possible pheochromocytoma complicated by cardiomyopathy,\n anuric kidney injury requiring CVVH\n REASON FOR THIS EXAMINATION:\n Please place PICC line. She has anaphylactic reaction to iodine.\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 44-year-old woman with possible pheochromocytoma,\n complicated by cardiomyopathy and acute renal failure, possibly secondary to\n either cardiogenic or septic shock. Patient is having CVVH via a left IJ\n temporary HD catheter. As longer term hemodialysis is anticipated, placement\n of a tunneled HD catheter was requested. Also, patient has not got any\n suitable peripheral IV access, so a double-lumen PICC line placement was\n requested.\n\n CLINICIANS: Dr. and Dr. . Dr. , the attending\n radiologist, was present and supervising throughout.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n 75 mcg of fentanyl and 1.5 mg of Versed throughout the total intraservice time\n of 30 minutes during which the patient's hemodynamic parameters were\n continuously monitored. Local anesthesia with 1% lidocaine and 1% lidocaine\n with epinephrine.\n\n PROCEDURE 1: Tunneled HD catheter placement:\n\n An informed written consent was obtained after explaining the procedure,\n benefits, alternatives and risks involved. Patient was brought to angiography\n suite and placed supine on the imaging table. The right side of the neck and\n upper chest were prepped and draped in the usual sterile fashion. Preprocedure\n huddle and timeout were performed as per protocol.\n\n Under ultrasound guidance, access was obtained into a patent right internal\n jugular vein with a micropuncture set and ultrasound images were saved\n digitally before and after obtaining venous access. Then, through the\n micropuncture sheath, the guidewire was upsized to a 0.035 wire which\n was advanced into IVC under fluoroscopic control after taking appropriate\n measurements. Then, attention was directed to creating a subcutaneous tunnel.\n After instilling 1% lidocaine with epinephrine, a small incision was made over\n the right upper chest. A 19 cm tip-to-cuff hemodialysis catheter was tunneled\n through and brought out at the venotomy site. Then, the soft tissue tract was\n dilated over the guidewire and peel-away sheath was placed. The inner dilator\n and guidewire were removed. The catheter was placed through the peel-away\n sheath and tip advanced into the right atrium and the peel-away sheath was\n (Over)\n\n 4:31 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line. She has anaphylactic reaction to iod\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n removed. Both ports of the catheter were easily aspirated and flushed and\n capped. A fluoroscopic spot chest film was obtained demonstrating\n satisfactory placement of the catheter with the tip terminating in the right\n atrium. The catheter was secured to skin with 0 silk sutures and the venotomy\n site closed with 4-0 Vicryl suture. Sterile dressings were applied. Patient\n tolerated the procedure well and there were no immediate complications.\n\n IMPRESSION: Successful uncomplicated, ultrasound and fluoroscopically-guided\n placement of a 15.5 French x 19 cm tip-to-cuff tunneled hemodialysis catheter\n via right internal jugular venous access with the tip of the catheter\n terminating in the right atrium. The line is ready for use.\n\n PROCEDURE 2: PICC LINE PLACEMENT\n\n INDICATION: IV access needed for antibiotics.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. with Dr. performed the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double lumen PICC line measuring 44 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French\n double lumen PICC line placement via a patent left basilic venous approach.\n Final internal length is 44 cm, with the tip positioned in SVC. The line is\n ready to use.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-17 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1193894, "text": " 3:23 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate RP bleed, ? ovarian mass vs. fibroid uterus,\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with suspected pheochromocytoma, in renal failure on CVVH,\n labile BPs, and likely catecholamine-induced cardiomyopathy\n REASON FOR THIS EXAMINATION:\n Please evaluate RP bleed, ? ovarian mass vs. fibroid uterus, and adrenal mass\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure, anaphylaxis;renal failure, anaphylaxis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old female with suspected pheochromocytoma, renal\n failure, labile blood pressures, and likely catecholamine-induced\n cardiomyopathy. Evaluate retroperitoneal bleed.\n\n COMPARISON: Abdominal and pelvic MRIs performed earlier the same day.\n\n TECHNIQUE: Non-contrast MDCT imaging of the abdomen and pelvis was performed,\n with preparation and review of multiplanar reformatted images.\n\n CT ABDOMEN WITHOUT CONTRAST:\n\n There are bilateral moderate nonhemorrhagic pleural effusions, with associated\n atelectasis. There is no pericardial effusion.\n\n Evaluation of the solid intra-abdominal organs is limited by lack of\n intravenous contrast. Within this limitation, the liver, gallbladder, biliary\n tree, spleen, and pancreas are normal. The left adrenal gland and kidneys are\n similarly unremarkable. There is no hydronephrosis or renal mass lesion\n identified.\n\n A right adrenal mass measures 4.5 cm AP x 4.0 cm transverse x 4.2 cm\n craniocaudad. This was better characterized on recent MRI, though on CT, it\n is noted to be of intermediate attenuation, not specifically suggesting an\n adenoma. The differential remains unchanged including possible\n pheochromocytoma, adrenal cortical carcinoma, or metastatic disease.\n\n The stomach, duodenum, and intra-abdominal loops of small and large bowel are\n unremarkable. There is no bowel distention or bowel wall thickening. There\n is no mesenteric or retroperitoneal adenopathy identified.\n\n CT PELVIS WITHOUT CONTRAST:\n\n In the pelvis, a Foley catheter is noted decompressing the bladder. The\n uterus is enlarged and lobulated in contour, compatible with presence of\n multiple fibroids. There is a small amount of free simple fluid in the\n cul-de-sac. Additionally, there is an extraperitoneal heterogeneously\n hyperdense collection, compatible with a moderate-sized hemorrhage. This is\n confined to the right pelvis, with hyperdense blood products seen tracking\n into the right inguinal canal.\n (Over)\n\n 3:23 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate RP bleed, ? ovarian mass vs. fibroid uterus,\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The distal ureters are unremarkable. The rectum and sigmoid are normal.\n There is no evidence of adnexal mass or pelvic adenopathy.\n\n BONE WINDOWS: There are no lytic or sclerotic osseous lesions identified.\n Mild degenerative changes are noted in the lower thoracic spine. There is\n mild soft tissue anasarca over the bilateral flanks.\n\n IMPRESSION:\n\n 1. Right adrenal mass, measuring up to 4.5 cm, as seen on MRI. Differential\n again includes pheochromocytoma, adrenal cortical carcinoma, and metastases.\n\n 2. Extraperitoneal hemorrhage, moderate in size, confined to the right\n pelvis.\n\n 3. Small free fluid, nonhemorrhagic, within the cul-de-sac.\n\n 4. Fibroid uterus. No evidence of adnexal mass.\n\n 5. Moderate bilateral nonhemorrhagic pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-17 00:00:00.000", "description": "MRI ABDOMEN W/O CONTRAST", "row_id": 1193754, "text": " 1:14 AM\n MRI ABDOMEN W/O CONTRAST Clip # \n Reason: Please evaluate adrenal and adnexal mass\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 yo woman with h/o anxiety who presented to an OSH ED with abdominal pain,\n became progressively more ill and was critically ill in CCU - intubated on\n pressors. Now with and labile BPs. Suspect pheochromocytoma\n REASON FOR THIS EXAMINATION:\n Please evaluate adrenal and adnexal mass\n CONTRAINDICATIONS for IV CONTRAST:\n suspect allergy - possibly anaphylaxis, currently on CVVH\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Further assess right adrenal lesion.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 T\n magnet.\n\n Comparison is made to CT examination from .\n\n FINDINGS: There is a 3.1 x 2.8 cm mass in the right adrenal gland. The\n lesion has susceptibility artifact on T1-weighted gradient-echo imaging,\n suggestive of hemorrhage. The lesion is predominantly low signal intensity on\n T2-weighted imaging though perhaps may be secondary to hemorrhage. There is\n no overt dropout on out-of-phase imaging (though limited by hemorrhage in the\n lesion) and no restricted diffusion.\n\n The imaging characteristics are relatively nonspecific and would include a\n pheochromocytoma, adrenocortical carcinoma, or metastasis. An adenoma would be\n less likely. This lesion should be amenable to percutaneous biopsy with\n adequate precaution for pheochromocytoma if clinically indicated.\n\n The spleen, left adrenal gland, kidneys, and liver are unremarkable.\n Bilateral pleural effusions are present. No destructive bone lesions.\n\n IMPRESSION:\n\n 3.1 cm right adrenal mass, nonspecific by imaging, but apparantly hemorrhagic\n in nature. Differential includes pheochromocytoma, adrenocortical carcinoma,\n or metastasis.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-17 00:00:00.000", "description": "MRI PELVIS W/O CONTRAST", "row_id": 1193755, "text": " 1:14 AM\n MRI PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate adnexal mass\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with adrenal and pelvic masses - suspect pheochromocytoma\n REASON FOR THIS EXAMINATION:\n Please evaluate adnexal mass\n CONTRAINDICATIONS for IV CONTRAST:\n suspect allergy; currently on CVVH\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Further assess right adnexal mass noted on previous CT\n examination.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 T\n magnet.\n\n FINDINGS: There is a 8.8 x 4.9 cm mass anterior to the right external iliac\n vessels which appears extraperitoneal. The mass is of high signal intensity\n on T1- and T2-weighted imaging, suggestive of a hematoma. It tracks\n superiorly along the right flank measuring 5.7 x 3.8 cm. In addition, there\n is a 2.2 cm well-defined hematoma in the right groin. The imaging features\n are consistent with an extraperitoneal hematoma which is tracking superiorly\n from the right groin, probably related to recent right groin catheterization.\n\n There is an anteverted, anteflexed uterus measuring 9.8 x 6.1 cm. A number of\n intramural fibroids are present, maximally measuring 3.1 cm. The right ovary\n is not well visualized. Left ovary appears normal. Free fluid is present\n superior to the bladder.\n\n No enlarged pelvic lymph nodes.\n\n IMPRESSION:\n\n 1. Large extraperitoneal hematoma, which appears to track superiorly from the\n right groin, presumably related to recent catheterization.\n\n 2. No adnexal masses. The abnormality noted on recent CT likely represents a\n dominant fibroid within the uterus.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1193399, "text": " 3:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: chest tube removed, please eval for pneumothorax\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44yoF with no PMHX, now critically ill - intubated, on CVVH in the ICU, suspect\n pheochromocytoma, course c/b pneumothorax - chest tube removed at 1500 today\n REASON FOR THIS EXAMINATION:\n chest tube removed, please eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: Patient with chest tube removal. Evaluate for\n pneumothorax.\n\n FINDINGS: Comparison is made to prior study from .\n\n There has been removal of the left-sided pigtail catheter. There is no\n residual pneumothorax. The rest of the support lines and tubes are stable and\n unchanged in position. There is again seen prominence of the pulmonary\n interstitial markings with more focal areas of confluence within the lung\n bases and this is again stable. The cardiac silhouette is within normal\n limits. A left retrocardiac opacity is again seen and unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1192348, "text": " 10:17 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval left chest tube placement\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman s/p chest tube placement for tension PTX.\n REASON FOR THIS EXAMINATION:\n eval left chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube placement for pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a pigtail catheter with re-expansion of the left lung. Remainder\n of the study is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1192624, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval progression\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with hypoxemic respiratory failure\n REASON FOR THIS EXAMINATION:\n Interval progression\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hypoxic respiratory failure, evaluation for progression.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Unchanged monitoring and support devices. Unchanged size of the\n cardiac silhouette. Unchanged right parenchymal opacities with air\n bronchograms. No newly appeared focal parenchymal opacities. Unchanged size\n of the cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-08 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1192317, "text": " 12:54 AM\n RENAL U.S. PORT Clip # \n Reason: eval for adrenal mass\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with cardiogenic shock. H/o recent tachycardia, diaphoresis,\n diarrhea. HTN to 200's on arrival to OSH. EF 25% on echo. Now hypotensive on\n 3 pressors. Concern for pheo causing cardiogenic shock.\n REASON FOR THIS EXAMINATION:\n eval for adrenal mass\n ______________________________________________________________________________\n WET READ: JBRe SUN 1:51 AM\n 1. 3.5 cm mass superior to the right kidney, likely representing adrenal mass.\n 2. Possible complex bilateral pleural effusions.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old woman with tachycardia and diarrhea.\n\n TECHNIQUE:\n Grayscale and color Doppler ultrasound images of the abdomen were performed.\n\n COMPARISON: Chest radiograph from and CT torso at from\n .\n\n FINDINGS:\n\n The echogenicity of the liver is normal with no focal lesions. There is no\n intra- or extra-hepatic biliary dilatation with the common bile duct measuring\n 3 mm. There is mild gallbladder wall edema and perihepatic free fluid. No\n evidence of gallstones, no evidence of acute cholecystitis.\n\n The portal vein is patent with normal hepatopetal flow. The right kidney is\n normal measuring 9.9 cm without evidence of hydronephrosis or stones. There is\n a 5 x 3.8 cm hypervascular lesion superior to the right kidney, likely\n representing a right adrenal gland mass. There are complex pleural effusions\n or basilar lung opacities bilaterally.\n\n The left kidney is normal measuring 9.4 cm. The spleen is normal measuring 8\n cm.\n\n A line is seen in the IVC and an NG tube is seen in the duodenum.\n\n IMPRESSION:\n 1. Right 5cm adrenal gland mass, as seen on the OSH CT from .\n 2. Bibasilar lung opacities.\n 3. Please consider further workup of a 7 x 8cm pelvic mass (also seen at the\n OSH CT from ) with a pelvic US.\n\n (Over)\n\n 12:54 AM\n RENAL U.S. PORT Clip # \n Reason: eval for adrenal mass\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2129-05-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1192345, "text": " 9:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval PTX\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with PTX s/p line placement\n REASON FOR THIS EXAMINATION:\n eval PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumothorax status post line placement.\n\n FINDINGS: In comparison with the study of , there is continued large\n pneumothorax with some element of tension on the left. This information has\n been discussed with the clinical team and a chest tube will soon be placed.\n\n Otherwise unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1192464, "text": " 7:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with chest tube, chf\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:42 \n\n HISTORY: Chest tube, question interval change.\n\n IMPRESSION: AP chest compared to through 5:\n\n Pulmonary edema is still more pronounced in the right lung continues to clear\n relative to . No appreciable left pneumothorax, apical pleural tube in\n place. There is no pleural effusion. Heart size normal. Left\n supraclavicular central venous line, ET tube, nasogastric tube in standard\n placements. Heart size normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1192826, "text": " 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with hypoxic respiratory failure, possible pheochromocytoma,\n pneumothorax s/p chest tube, renal failure - critically ill in CCU\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with hypoxic respiratory failure. Assess for interval\n change.\n\n COMPARISONS: Chest radiographs of , , .\n\n FINDINGS:\n\n Normal lung volumes. Diffuse bilateral opacities are nearly resolved. Left\n lower loba opacity obscures left hemidiaphragm, new since prior exam. There\n is no pleural effusion or pneumothorax. The hilar and mediastinal silhouettes\n are unchanged. Heart size is normal.\n\n Pigtail catheter projects over left upper hemithorax. Left IJ line terminates\n at mid to lower SVC. NG tube tip is not imaged. An ET tube terminates 5 cm\n above the carina.\n\n IMPRESSION:\n\n 1. Left lower lobe opacity is new from exam and is concerning for\n infection.\n\n 2. Diffuse bilateral parenchymal opacities are resolved.\n\n" }, { "category": "Echo", "chartdate": "2129-05-27 00:00:00.000", "description": "Report", "row_id": 78800, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. History of CM, pheochromocytoma\nHeight: (in) 64\nWeight (lb): 185\nBSA (m2): 1.89 m2\nBP (mm Hg): 120/63\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 11:42\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low normal LVEF. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal\narch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Normal mitral\nvalve supporting structures. No MS. Trivial MR. Normal LV inflow pattern for\nage.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nThickened/fibrotic tricuspid valve supporting structures. No TS. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is low normal (LVEF 50%). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. The\nsupporting structures of the tricuspid valve are thickened/fibrotic. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is increased.\n\n\n" }, { "category": "Echo", "chartdate": "2129-05-12 00:00:00.000", "description": "Report", "row_id": 78801, "text": "PATIENT/TEST INFORMATION:\nIndication: Dilated cardiomyopathy.\nHeight: (in) 66\nWeight (lb): 168\nBSA (m2): 1.86 m2\nBP (mm Hg): 112/72\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 14:31\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal regional LV systolic function. Severely depressed LVEF.\nNo resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. \n(<140ms) transmitral E-wave decel time.\n\nTRICUSPID VALVE: Physiologic TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - patient unable to cooperate.\nResting tachycardia (HR>100bpm).\n\nConclusions:\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is severely depressed (LVEF= 25 %) with relative\npreservation of the apical segments. . Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic stenosis or aortic\nregurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nnormal. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Focused views. Severely depressed global left ventricular systolic\nfunction with relatively preserved apical segments. No clinically significant\nvalvular disease. Normal pulmonary artery systolic pressures.\n\nCompared with the prior study (images reviewed) of , no interval\nimprovement in global left ventricular systolic function.\n\n\n" }, { "category": "Echo", "chartdate": "2129-05-09 00:00:00.000", "description": "Report", "row_id": 78802, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. F/U cardiogenic shock.\nHeight: (in) 66\nWeight (lb): 168\nBSA (m2): 1.86 m2\nBP (mm Hg): 116/60\nHR (bpm): 130\nStatus: Inpatient\nDate/Time: at 09:26\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\npt intubated on vent.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate-severe\nglobal left ventricular hypokinesis. Relatively preserved apical LV\ncontraction.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Results were\nreviewed with the Cardiology Fellow involved with the patient's care.\nEchocardiographic results were reviewed with the houseofficer caring for the\npatient.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses and cavity size are normal. There is moderate to severe\nglobal left ventricular hypokinesis (LVEF = 25%). Systolic function of apical\nsegments is relatively preserved (suggestive of a non-ischemic\ncardiomyopathy). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic stenosis or aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno mitral valve prolapse. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with\nsevere hypokinesis of the basal 2/3rds of the ventricle in a pattern\nsuggestive of a non-ischemic cardiomyopathy. Normal right ventricular cavity\nsize and free wall motion.\nCompared with the prior study (images reviewed) of , global left\nventricular systolic function is slightly improved. The right ventricular\ncavity appeared dilated and hypokinetic on review of the prior study, with\nimprovement in the current study.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Echo", "chartdate": "2129-05-07 00:00:00.000", "description": "Report", "row_id": 78803, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease.\nHeight: (in) 66\nWeight (lb): 66\nBSA (m2): 1.25 m2\nBP (mm Hg): 117/80\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 18:14\nTest: TTE (Focused views)\nDoppler: Color Doppler only\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Severely depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- akinetic; mid anterior - hypo; basal anteroseptal - akinetic; mid\nanteroseptal - hypo; basal inferoseptal - akinetic; mid inferoseptal - hypo;\nbasal inferior - akinetic; mid inferior - hypo; basal inferolateral -\nakinetic; mid inferolateral - hypo; basal anterolateral - akinetic; mid\nanterolateral - hypo;\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). ?# aortic valve leaflets. No\nAR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Normal mitral\nvalve supporting structures.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm). Emergency study performed by the cardiology fellow on\ncall.\n\nConclusions:\nOverall left ventricular systolic function is severely depressed (LVEF= 20 %)\nsecondary to akinesis of all basal segments, hypokinesis of the midventricular\nsegments, and relative preservation of apical function, although the true apex\nwas poorly visualized. The aortic valve leaflets (?#) appear structurally\nnormal with good leaflet excursion. The number of aortic valve leaflets cannot\nbe determined. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no pericardial\neffusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1192551, "text": " 2:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Interval change. Please perform at 3 pm\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with pneumothorax s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n Interval change. Please perform at 3 pm\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADGIOGRAPH\n\n INDICATION: Pneumothorax, status post chest tube removal.\n\n COMPARISON: , 7:42 a.m.\n\n FINDINGS: Unchanged monitoring and support devices. No evidence of\n pneumothorax. A left chest tube remains in place. No pulmonary edema.\n Normal size of the cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1192280, "text": " 2:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ett placement, pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with chest pain, intubated\n REASON FOR THIS EXAMINATION:\n eval for ett placement, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old woman, with chest pain. Status post intubation. Assess\n for ET tube placement and pulmonary edema.\n\n COMPARISON: None.\n\n SINGLE AP SUPINE CHEST RADIOGRAPH: There is marked bilateral\n centrally-predominant diffuse opacification, right worse than left, compatible\n with pulmonary edema. Superimposed focal airspace consolidations cannot be\n excluded, particularly on the right. The cardiomediastinal silhouette is\n within normal limits. There are no pleural effusions or pneumothorax. The\n endotracheal tube terminates approximately 4.7 cm above the carina. The NG\n tube terminates in the stomach.\n\n IMPRESSION: Marked bilateral centrally-predominant opacification, compatible\n with severe pulmonary edema. Superimposed consolidation/infection cannot be\n excluded.\n\n Endotracheal and nasogastric tubes are in appropriate position.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1192310, "text": " 10:42 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? line placement\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with cardiogenic shock\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiogenic shocks, for line placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a left IJ catheter that extends to the mid portion of the SVC.\n However, there has also been the development of a large left pneumothorax.\n\n This information has been telephoned to Dr. at 8:15 a.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-08 00:00:00.000", "description": "PELVIS, NON-OBSTETRIC", "row_id": 1192378, "text": " 2:04 PM\n PELVIS, NON-OBSTETRIC Clip # \n Reason: Please perform transabdominal and transvaginal U/S to evalua\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman adrenal and pelvic masses seen on recent -N CT scan,\n critically ill in CCU, concern for pheochromocytoma, want to further evaluate\n pelvic mass\n REASON FOR THIS EXAMINATION:\n Please perform transabdominal and transvaginal U/S to evaluate pelvic mass\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 44-year-old female with adrenal and pelvic\n masses noted on recent CT examination with concern for pheochromocytoma. For\n further evaluation of the pelvic mass.\n\n EXAMINATION: Non-obstetric pelvic ultrasound.\n\n COMPARISONS: Examination as compared to ultrasound from and \n examination performed .\n\n FINDINGS:\n\n Transabdominal ultrasound examination was performed in the ICU.\n The scan demonstrates an enlarged fibroid uterus measuring 13.0 x 5.7 x 5.8\n cm. There are multiple fibroids, the largest measuring 3.7 x 3.8 x 3.7 cm\n demonstrated within a mid body location. The endometrium measures up to 7 mm\n and is unremarkable in appearance. The left ovary is normal.\n\n In addition, focused scanning of the right adnexa was performed. Demonstrated\n centered within the right adnexa, there is an 8.9 x 5.6 x 5.7 cm heterogeneous\n in echogenicity solid mass that is immediately adjacent to the uterine fundus,\n though it does not demonstrate the typical claw sign that suggests it arises\n from the uterus. In addition, this right adnexal mass engulfs the right ovary\n but does not definitively appear to arise from the right ovary which appears\n normal in appearance measuring 3.1 x 1.7 x 2.4 cm. There is no pelvic free\n fluid.\n\n IMPRESSION: 8.9 cm right adnexal mass appears to engulf the right ovary but\n does not appear to arise from it and appears immediately adjacent to the right\n uterine fundus, though it does not show typical signs that it arises from it.\n This suggests that it may be adnexal in origin and a differential possibility\n includes extra-adrenal paraganglioma, given the known right adrenal mass. For\n further characterization of this lesion, MRI would be very helpful.\n\n" }, { "category": "Radiology", "chartdate": "2129-05-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1192426, "text": " 9:23 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with L PTX, chest tube in place\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with history of left pneumothorax. Assess for interval\n change.\n\n COMPARISONS: Multiple chest radiographs dating back to .\n\n FINDINGS:\n\n Lung volumes are normal. Diffuse bilateral opacities, right greater than\n left, are again noted. Right upper upper zone opacity appears improved.\n Right mid and low lung zone opacities are unchanged. Left lung opacity is\n impoved peripherally, otherwise unchanged. Possible pulmonary nodule in the\n right medial lung base. No pleural effusion. Heart size is normal. The\n hilar and mediastinal silhouettes are unchanged.\n\n An endotracheal tube terminates 5 cm above the carina. Pigtail catheter\n projects over left upper hemithorax. No pneumothorax. Left central venous\n catheter projects over mid SVC. Nasogastric tube tip is out of view.\n\n IMPRESSION:\n\n 1. Diffuse bilateral opacities, right greater than left, mildly improved from\n prior exam, as detailed above. Findings compatible with pulmonary edema,\n however superimposed infection cannot be excluded.\n\n 2. Possible pulmonary nodule in the right medial lung base. Consider\n dedicated chest radiographs following resolution of bilateral opacities.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2129-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1192296, "text": " 6:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate for PNA\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with no significant PMH who presents with shock.\n REASON FOR THIS EXAMINATION:\n Please evaluate for PNA\n ______________________________________________________________________________\n WET READ: ENYa SAT 10:59 PM\n Marked, diffuse, bilateral opacities, R > L. DDx is broad, including\n pulmonary edema, alveolar hemorrhage, pneumonia or hypersensitivity\n pneumonitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shock.\n\n FINDINGS: No previous images. The cardiac silhouette is mildly enlarged.\n Diffuse opacifications seen throughout both lungs. Although this could\n represent widespread pneumonia, the possibility of severe pulmonary edema or\n even ARDS should be considered.\n\n Endotracheal tube tip lies approximately 5.8 cm above the carina. Nasogastric\n tube extends well into the stomach. What appears to be a femoral Swan-Ganz\n catheter extends to the region of the pulmonary outflow tract.\n\n\n" }, { "category": "ECG", "chartdate": "2129-05-28 00:00:00.000", "description": "Report", "row_id": 210202, "text": "Sinus rhythm. Prolonged P-R interval. Compared to the previous tracing\nof there is no change.\n\n" }, { "category": "ECG", "chartdate": "2129-05-26 00:00:00.000", "description": "Report", "row_id": 210203, "text": "Sinus rhythm. Borderline P-R interval prolongation. Borderline\nlow limb lead voltage. Late R wave progression. Since the previous tracing\nof the rate is faster. RSR' pattern in leads V1-V2 is less apparent.\nChange in R wave progression may be related to lead position.\n\n" }, { "category": "ECG", "chartdate": "2129-05-26 00:00:00.000", "description": "Report", "row_id": 210204, "text": "Sinus rhythm with A-V conduction delay. RSR' pattern in leads V1-V2 may be a\nnormal variant. Low limb lead QRS voltage. Modest lateral limb lead T wave\nchanges. Findings are non-specific. Since the previous tracing of \nlateral limb lead T wave amplitude is lower.\n\n" }, { "category": "ECG", "chartdate": "2129-05-20 00:00:00.000", "description": "Report", "row_id": 210205, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of the\nrate is slower.\n\n" }, { "category": "ECG", "chartdate": "2129-05-11 00:00:00.000", "description": "Report", "row_id": 210206, "text": "Sinus tachycardia. Left anterior fascicular block. Probable anterior wall\nmyocardial infarction of indeterminate age. ST-T wave abnormalities. Cannot\nexclude myocardial ischemia. Clinical correlation is suggested. Since the\nprevious tracing of further ST-T wave changes are present.\n\n" }, { "category": "ECG", "chartdate": "2129-05-09 00:00:00.000", "description": "Report", "row_id": 210207, "text": "Sinus tachycardia. Left anterior fascicular block. Poor R wave progression.\nConsider anteroseptal myocardial infarction. Diffuse ST-T wave abnormalities.\nCompared to the previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2129-05-08 00:00:00.000", "description": "Report", "row_id": 210208, "text": "Probable sinus tachycardia. Since the previous tracing the rate is slower.\nOther features unchanged.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2129-05-07 00:00:00.000", "description": "Report", "row_id": 210209, "text": "Sinus or other supraventricular tachycardia. Since the previous tracing\nthe rate is faster and there is now a fusion of the P wave with the T wave\nsuggesting sinus tachycardia.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2129-05-07 00:00:00.000", "description": "Report", "row_id": 210210, "text": "Baseline artifact. Probable sinus tachycardia. Leftward axis. Consider left\nanterior fascicular block. Possible septal infarction. RSR' pattern,\nborderline in the early precordial leads. ST-T wave abnormalities. No\nprevious tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2153-08-04 00:00:00.000", "description": "Report", "row_id": 1546478, "text": "pmicu nursing update\n\nresp: resp rate 14-23 with o2 sats of 99-100%\n\ncardiac: bp 102-111/37-53 with a pulse of 59-77 sb/sr. no ectopy noted. Iv of d5w and bicarb dc'd at approx 12p.\n\ngu: urinary output since approx 10p has been 1700cc.\n\nid: temp 96.8 axillary.\n\nneuro: last ativan was at approx 2:30p.\n" }, { "category": "Nursing/other", "chartdate": "2153-08-04 00:00:00.000", "description": "Report", "row_id": 1546476, "text": "S/MICU Nursing Admission/transfer Note\n Pt is a 42y/o man who was found down by BU police, in the Ew pt found to have a ETOH level of 154, and phenobarbital level of 56.9, pt arrived to the EW with slurred speech, cooperative, and intoxicated. He was treated with NaHCO3 IV push and then in IV infusion. Admitted to S/MICU for observation.\n\n PMH: hep C, seizures, polysubstance abuse.\n\n Allergies: codine...rash and throat swelling.\n\n Review of System:\n\n Neuro: pt alert and oriented x2, (knew place, time but stated )unsteady gait, tremors of hands, denies any nausea, following CIWA scale, pt rated 13 at 12:30am treated with 2mg of po ativan. pt is cooperative, recieved a dose of charcoal at 1am,\n\n Cardiac: Hr 60-70's NSR with no VEA, BP stable 120-130/60's on D5w with 3 amps of NaHCO3 at 200cc/hr. foley in place and draining.\n\n Respiratory: on RA, O2 sat 98-100's Lungs clear.\n\n GI: diarrhea from charcoal, stool x4 tonight.\n\n IV's #20 angio's\n" }, { "category": "Nursing/other", "chartdate": "2153-08-04 00:00:00.000", "description": "Report", "row_id": 1546477, "text": "pmicu nursing progress note\ncardiac: bp 108-120/56-60 with a pulse of 60-68 sr, no ectopy noted. k+ was 3.3 and pt given 40 meq of kcl po. iv of d5w with bicarb is infusing at 200cc/hr x1 liter/\n\nresp: on room air with o2 sats of 96-98% and a resp rate of 15-20. lung soundswere slightly deminished in the lll and rul, otherwise clear. non-productive cough.\n\nid: temp was 98po. wbc was 8.5\n\ngi: abdomin soft, with + bowel sounds. glu was 71 and pt now eating breakfast. last liquidy stool was passed on nocs---black from the charcoal.\n\ngu: foley in place, urine output approx 50cc/hr. bun 15 and creat .6. ph of urine was 7 at 9a.\n\nneuro: pt alert and knew the month/year and where he was. following commands. given 2mg of ativan at approx 8:30a--per the ciwa scale--pt slightly tremulous holding out arms, and diaphoretic. pt also intermittently feels very anxious. phenobarb level was 38.4 at 6a today. given a second dose of charcoal at 8a.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2137-12-14 00:00:00.000", "description": "Report", "row_id": 1514809, "text": "CONDITION UPDATE:\nD/A: T MAX 99.9\n\nNEURO: A+OX3, MAE, PERL, FOLLOWS COMMANDS. AT TIMES PT AGITATED, REDIRECTED VERBALLY. C/O OF PAIN X1 TREATED WITH DILAUDID WITH GOOD EFFECT. VENT DRAIN INTACT, ICP ~10. HEAD DSD INTACT, JP WITH SERO-SANG DRG. NIMODOPINE D/C'D.\n\nRESP: LS CLEAR, DIMINISHED IN BASES. 2 L/M O2 VIA NC.\n\nCV: HR 70'S, NSR RARE PVC'S. QTC .41 DR. AWARE. FLUID BALANCE MN-0500 -470CC'S DESPITE IVF AVF TOTALLY 210CC'S/HR. GOAL SBP 140-160 WITH TITRATION OF NE0.\n\nGI: TOLERATING SIPS OF CLEARS WELL. ABP SOFT. NO NAUSEA.\n\nGU: FOLEY-BSD WITH CLEAR URINE.\n\nR: NEO GTT FOR SBP 140-160 CONTINUES. HHH ? STOP TODAY.?\n\nP: CONTINUE WITH CURRENT PLAN AND CLOSE MONITORING.\n\n" }, { "category": "Nursing/other", "chartdate": "2137-11-29 00:00:00.000", "description": "Report", "row_id": 1514782, "text": "CONDITION UPDATE\nD.WHEN TEMP SPIKED TO 101-102(X2),PT HYPERTENSIVE TO 200 FOR WHICH SHE RECEIVED HYDRALAZINE WHICH DECREASED SBP SLIGHTLY. SBP DROPPED <170 AFTER PT RECEIVED TYLENOL FOR TEMP AND COINCIDENTLY HER NIMODIPINE TO THE POINT OF REQUIRING 2 FLUID BOLUSES AND VERY SHORT TIME,NEO..PT HAD NO CHANGE IN NEURO STATUS WITH HBP OR WITH LOWER BP.PT RESPONDED TO FLUID BOLI.CVP 6-12.\n PT REMAINS LETHARGIC BUT EASILY AROUSED.SHE FOLLOWS COMMANDS BUT USUALLY HAS A COMMENT THAT IS SOMEWHAT SARCASTIC..PT FOLLOWS ALL COMMANDS AND MOVES ALL EXTREMITIES EQUALLY.\nA.HEAD CT DONE..PANCULTURED.LINE CHANGED TODAY..CONTINUE TO MONITOR FOR VASOSPASMS.\nR.STABLE AT THIS TIME.\n" }, { "category": "Nursing/other", "chartdate": "2137-11-30 00:00:00.000", "description": "Report", "row_id": 1514783, "text": "Condition Update B:\nPlease refer to careview and remarks for details.\n\nNSS. Alert or easily arouasble, oriented x3. At start of shift pt accusing husband of telling her he slept in , telling RN she did not know what country she was in. Very apologetic to caregivers when they enter room, then continues to be uncooperative during care. When questioned, pt answers \"I want to see what you will do\". Orbital edema decreasing. Ventricular drain patent, dsg C/D/I. ICP 3-10.\n\nTmax 100.8 po. Tylenol po admin x3. WBC slightly improved. Hydralazine x1 for SBP ^204. BP decreases with admin of nimodipine. Goal 160-180's.\n\nPt auto diuressing. Electrolytes repleted. Taking good po fluids. No inications of aspiration. Abd s/nt pos BS. Small loose brown bm gauiac neg. Pos flatus.\n\nPLAN: Cont with HHH therapy. Sitter for pt saftey and treatment interference. Cont with ICU care and monitoring. Call H.O. for changes.\n" }, { "category": "Nursing/other", "chartdate": "2137-11-30 00:00:00.000", "description": "Report", "row_id": 1514784, "text": "npn\nNeuro- A+o x3, mae wnl, pearl. Dilantin 100 mg iv tid, nimodipine 2 po q4. Denies ha. vent drain 10 above tragus, icp 7-11. Draining clear to light blood tinged drg.\n\nResp_ lungs clear, instructed on incentive spirometer this am, using q1 with assist. sao2 on room air 97-98%.\n\nGI_ tol house diat, bm x2. colace .\n\nTemp max 101.2, pan cx . tylenol prn.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-14 00:00:00.000", "description": "Report", "row_id": 1514810, "text": "Condition Update A:\nPlease refer to careview and remarks for details.\n\nPt alert and oriented x3, MAE, PERL 3-4mm bilat brisk, NSS. Mood labile. Periods where pt became very agitated and irritable and unable to redirect. Attempted to contract care with pt regarding BP cuff, Pox, and NC. Pt stated \"I understand, I understand\", but would \"forget\". Unable to admin haldol due to prolonged QTc 0.43-0.44. Bilat wrist restraints applied at 1900 when pt found to have removed above monitors and NC. Dr. notified.\n\nICP 10-16. Vent dsg intact. Vent draining clear fluid. (L) head incision dsgs C/D/I.\n\nDilaudid IV admin for c/o HA with good effect.\n\nNeo gtt titrated off. SBP 102-127. No BP parameters. Hct 24. PRBC up at 1854.\n\nU/O decreased to 10ccx2h. Fluid bolus x1 admin with effect.\n\nPLAN: Monitor pt safety, wrist restraint. Monitor Neuro signs, ICP, vent drain output. Transfuse total of 2u PRBC, follow hct. Monitor u/o. Cont with ICU care and monitoring. Call H.O. for changes.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-15 00:00:00.000", "description": "Report", "row_id": 1514811, "text": "nursing note\n T. MAX 99.3. NSR, OCCASIONAL PVC'S. CVP 8-11. OFF NEO GTT AND BLOOD PRESSURE RANGE 104-145. NO PARAMETERS AS LONG AS NEURO STATUS REMAINS STABLE.\n NEUROLOGICALLY INTACT, NO CHANGES. OCCASIONAL AGITATION. ICP'S DEPENDING ON LEVEL OF AGITATION.ORDER OBTAINED FOR SOFT WRIST RESTRAINTS AS SHE WAS PULLING AT ALL TUBES, REMOVING O2, TAKING BLOOD PRESSURE CUFF OFF. ATIVAN GIVEN WITH GOOD EFFECT, CALM, FOLLOWING COMMANDS, NO CHANGES NEUROLOGICALLY.. VENTRICULAR DRAIN REMAINS AT 12 CM ABOVE THE TRAGUS. DRAINING CLEAR FLUID IN MODERATE AMOUNTS. SEE CARE VUE FOR SPECIFICS.\n HCT DRAWN IN AFTERNOON 24.2. 2 UNITS RBC'S GIVEN. POST-TRANSFUSION HCT DRAWN, RESULTS PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-01 00:00:00.000", "description": "Report", "row_id": 1514785, "text": " \"B\" Nsg Progress Note:\n\nPt with SAH,Coiling,Vent drain,Vasospasm.\n\nCVS: T101.2-102.0 po. Given tylenol with no effect. pt was pan cultured yest. HR=87-93 NSR w VR PVC noted. SBP mostly 170's but dipped to 155 at 11pm and was given 500cc NS IV bolus. Then at 3AM up to 200, given extra dose of Hydralazine 10mg. Since SBP=160-175. CVP= mostly. IV NS+20Meq KCL at 100cc/h. Skin warm and dry. Pulses palpable.\n\nResp: RA sats=96-99%, no SOB,Tachypnea,or bradypnea noted. Lung sounds clear. Will do breathing exercises but dislikes IS.\n\nNeuro: Intact, No changes,Very restless at times and throws legs over side rail to try to get up but is restrained and has 1:1 sitter to provide safety watch. ICP= mostly with a dip at 11PM to 4 when received fluid bolus as noted above. Ventriculostomy drain=33cc out clear.\n\nGI: Taking House diet. +bowel sounds.\n\nGU: U/O=135-380cc/h light yellow urine. Pt has menses.\n\nSkin: Incision line on head clean and dry. Dsg on drain site. No other red areas noted.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-12-09 00:00:00.000", "description": "Report", "row_id": 1514801, "text": "FOCUS: STATUS UPDATE\nDATA:\nPT ALERT AND ORIENTED X3. ABLE TO MOVE ALL EXTREMITIES WITH NORMAL EQUAL STRENGTH AND DENIES WEAKNESS. COMPLAINS OF CONSTANT HEADACHES WHICH ARE DIMINISHED WITH DIALAUDID PO BUT DO NOT GO AWAY. PATIENT IS ANGRY AND NON-COMPLIANT AT TIMES BUT OVERALL HAS BEEN CALMER TODAY THAN OVER THE WEEKEND. AT BEDSIDE FOR SAFETY. PATIENT IS UNRESTRAINED AND HAS BEEN INSTRUCTED NOT TO TOUCH VENTRICULOSTOMY CATHETER. SHE DOES, HOWEVER SCRATCH SCALP VERY NEAR AREA FREQUENTLY AND LOOSENS DRESSING. ICP HAS BEEN AT 12CM ABOVE TRAGUS SINCE AM. CLEAR DRAINAGE FROM VENTRICULOSTOMY.\n\nCONTINUES TO REQUIRE NEO GTT TO MAINTAIN HYPERTENSIVE STATE AS ORDERED-SEE CAREVUE FOR VITALS. ALBUMIN GIVEN AS ORDERED. NIMODIPINE WITH SLIGHT HYPOTENSION 1HR POST ADMINISTRATION.\n\nAPPETITE HAS BEEN POOR AND SHE HAS REFUSED OFFERS OF SPECIAL FOOD ORDERS.\n\nLARGE URINE OUTPUT CONTINUES.\n\nPLAN:\nCONTINUE TRIPLE H THERAPY AS ORDERED. CONTINUE AT BEDSIDE. PROVIDE EMOTIONAL SUPPORT AS NEEDED AND ENCOURAGE COMPLIANCE IN HER OWN CARE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-12-10 00:00:00.000", "description": "Report", "row_id": 1514802, "text": "Focus: Status update\nPt alert, oriented, cooperative on haldol. Pupils equal and reactive. Vent drain at 15 cm above tragus and draining clear CSF. ICP 2-7. Temp max 99.3. Medicated with PO dilaudid for HA with effect per pt.\n\nNormal sinus rhythm on telemetry with PVC's. Heart rate 70's-80's. Blood bressure kept 160's-180's with neo as ordered. CP . Recieved 2- 500cc IVF boluses for negative fluid status. No edema.\n\nLungs clear. O2 sats 97-98% on room air.\n\nAbdomen soft. Bowel sounds present. Tolerating regular diet.\n\nFoley with large amounts clear, yellow urine.\n\nPlan: Continue to monitor neuro status closely. HHH therapy. Emotional suppor. Vent drain at 15 above tragus and open to drainage. Moniotr for signs and symptoms of infection. Pain control as necessary.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-11 00:00:00.000", "description": "Report", "row_id": 1514805, "text": "NURSING NOTE 7A-7P REVIEW OF SYSTEMS:\nNEURO: DOOZING IN LONG NAPS, ALERT, ORIENTED, PLEASANT AND COOPERATIVE. PERLA, MAEW. TRANSFERED OOB TO COMMODE WITH ASSIST OF TWO. MEDICATED WITH HALDOL 1MG Q6HRS WITH GOOD EFFECT NO AGITATION PRESENT CANCELLED FOR TONITE. MEDICATED WITH DILAUDID 1MG X1 WITH GOOD EFFECT. BRAIN DRAIN INTACT DRAINING CLEAR YELLOW FLUID IN SMALL AMTS 20CC/HR. ICP READINGS 0-3.\nC/V: NSR RATE 60-80'S OCCASIONAL PVC NOTED. CONTINUES ON NEO AT 1.4MCG/KG/MIN. BP STABLE 140-160'S INCREASED TO 180'S ON ONE OCCASSION WHILE PATIENT BECAME AGITATED.\nRESP: LUNG SOUNDS CLEAR DIMINISHED BASES, O2 SAT 97-99%, RR= 14-24.\nGI: TAKING PO'S IN SMALL AMOUNTS, OOB TO COMMODE LARGE SOFT BROWN/GREEN STOOL.\nGU: FOLEY PATENT DRAINING LARGE AMOUNTS CLEAR YELLOW URINE CURRENTLY NEGATIVE 800CC TODAY.\nENDO: NO INSULIN COVERAGE NEEDED FS= 117 AND 95.\nSOCIAL: NO VISITORS FROM FAMILY TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-12 00:00:00.000", "description": "Report", "row_id": 1514806, "text": "NPN\nN: PT A/OX3. SEE CAREVUE FOR SERIAL NEURO SIGNS. GIVEN FIORICET X1 FOR HA PAIN AT NOON WITH RELIEF. REPEAT HEAD CT DONE THIS AM. CONT HHH THERAPY.\nCV: HD STABLE MAINTAINING SBP 140-160/ ON NEO GTT.\nR: LUNGS CLEAR THROUGHOUT ON RA SATS 100%. RR TEENS\nGI: TOL HOUSE DIET WITHOUT DIFFICULTY.\nGU: BRISK DIURESIS CLEAR YELLOW URINE.\nID; AFEBRILE. CONT KEFZOL FOR DRAIN PROPH.\nENDO: GLUCOSE 110'S.\nA/P: CONT WITH HHH. EMOTIONAL SUPPORT/ENCOURAGEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-13 00:00:00.000", "description": "Report", "row_id": 1514807, "text": "CONDITION UPDATE:\nD/A: T MAX 99.8\n\nNEURO: PT DOZING, A+OX3, MAE OFTEN AND FREQUENTLY. C/O HA, TREATED WITH FIUROCET WITH GOOD EFFECT. DECLINING MOST NURSING CARE, REFUSING TO USE BLOOD PRESSURE CUFF MORE FREQUENTLY THAT ONCE AN HOUR.\nVENTRICULAR DRAIN @ 12 ABOVE TRAGUS, OPEN, CLEAR DRAINAGE.\n\nCV: HR 70'S-80'S NSR. SBP LABILE WITH GOAL BP 140-160 MET WITH NEO GTT, SLIGHTLY TITRATED DOWN. FLUID BALANCE MN-0500 -726 CC'S.\n\nRESP: LS CLEAR UPPER, DECREASED IN BASES.\n\nGI: TOLERATING REGULAR DIET WELL.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nR: NO CHANGES NEUROLOGICALLY, SLIGHT WEAN ON NEO.\n\nP: CONTINUE CLOSE MONITORING AND MANAGEMENT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-12-13 00:00:00.000", "description": "Report", "row_id": 1514808, "text": "Condition Update A:\nPlease refer to careview and remarks for details.\n\nNEURO: Upon admit easily arousable oriented x3, following commands. MAE, became very agitated during neuro assessment, c/o pain in head \"burning\", attempting to take face mask off, bringing hands to head. Haldol 1mg IVP admin with no effect. Bilat wrist restraints applied to prevent harm to self. Dilaudid 2mg IVP admin with good effect. PERL 2mm/2mm brisk. Weak cough. Unable to assess gag. Vent drain open leveled to 12 above tragus. Wave form dampened and registering (-) numbers. Dr. notified of the above events and vent wave form.\n\nCV: Titrating neo gtt for SBP 140-160. HR initially 60's with occ PVC's. HR currently 80's with rare PVC's.\n\nLS CTA dim through out. Pt found face mask \"too close\", switched to NC. Pox 100% on 4L.\n\nPLAN: Monitor NS, vent drain and output, ICP. Monitor comfort level admin PRN pain med. Monitor for agitation, Qtc interval, admin PRN haldol. Titrate Neo gtt to keep SBP 140-160. Start Vanco tonight. Cont with ICU care and monitoring. Call H.O. with changes.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-10 00:00:00.000", "description": "Report", "row_id": 1514803, "text": "NPN\nSee carevue for details and remarks::\n\nNeuro: Very sleepy today. Easy to arouse. Appropriate when asked questions. Pupils reactive. Vent drain @ 15mm above tragus. Draining small amts clear CSF. HA w/+effect from PO dilaudid. ICP 2-7.\n\nCV: Still on Neo gtt, to titrate SBP 140-160. SBP after nimodipine SBP dips down to 117 HR 60-80s. Pt noncompliant w/BP cuff, takes off. CVP 6-9. R CVL w/ IV fluids. Still having multiple PVCs.\n\nResp: Lungs clear, diminished at bases. 97-98% RA, noncompliant w/O2 sat monitoring.\n\nGI: +hypoactive BS, nondistended, nontender. Refusing to eat, only taking in fluids (gingerale). Refused stool softener this am.\n\nGU: Clear, yellow urine moderate amts.\n\nSkin/mobility: Moving self in bed for comfort.\n\nPlan: Cont to wean neo gtt for SBP 140-160. Monitor MS, 1:1 dc'd this afternoon, to have a 11p-7a tonight. haldol a/o, Monitor vent drain, foley as needed.\n\n" }, { "category": "Nursing/other", "chartdate": "2137-12-11 00:00:00.000", "description": "Report", "row_id": 1514804, "text": "COMMUNICATION UPDATE\n NEURO STATUS INTACT, SEE CARE VUE FOR SPECIFICS. RECIEVING HALDOL ATC WITH GOOD EFFECT. CALM, COOPERATIVE, FOLLOWING COMMANDS. IN PLACE AT 11 P.M. BUT SO FAR TONIGHT IT HAS BEEN UNNECESSARY.\n VITAL SIGNS STABLE, CONTINUES ON NEO TO KEEP SBP 140-160. BLOOD PRESSURE NOT DROPPING AS SEVERLY AS PREVIOUSLY WITH NIMODIPINE DOSE DECREASED TO 30. WILL CONTINUE TO MONITER.\n MEDICATED FOR COMPLAINT OF HEADACHE WITH DILAUDID PO WITH GOOD EFFECT.\n" }, { "category": "Nursing/other", "chartdate": "2137-11-25 00:00:00.000", "description": "Report", "row_id": 1514772, "text": "NPN 0830-\n\n see careview for details:\npatient returned from OR at 8:30am s/p craniectomy for increased ICPs.\n\nEVENTS: with turning and suctioning patient had episodes of bradycardia into the 40s, ABP remained stable and HR returned to baseline 60-70s immediately. team aware.\n\nNEURO: patient arrived from OR sedated on propofol. propofol was weaned throughout day and now off propofol; exam as follows: patient following commands, PERLA, arousing to verbal stimulation, moving all extremities purposefully, oriented to self, states the year is \"later than \", knows she is in the hospital but forgets which one. Ventriculostomy drain 10cm above tragus draining drops of CSF, flushed by N- for patency, ICPs ranging from 15-19, dilantin dosing continues (level 4.7)\n\nCV/HEME: BP goal less than 120, nipride and labetolol drips weaned throughout day and patient now maintain ABP 110s/50s with occasional increases to 120s, NSR 60-70, with above noted brady episodes, no ectopy. Nimodipine capsules given Q4H as ordered, lytes repleted. HCT stable.\n\nRESP: patient was extubated at 1600 and is maintaining O2 sats greater than 94% on tent face mask. prior to extubation patient weaned from SIMV to CPAP and tolerated weaning. Patient was suctioned for thick yellow sputum and now has a productive strong cough and is able to expectorate thick yellow sputum.\n\nGI/GU: abd s/nt/nd, hypoactive BS, OGT tube dc'd at extubation. NPO maintain. Foley catheter draining clear yellow urine in adequate amounts.\n\nENDO: no coverage need for blood glucose.\n\nID: tmax today was 100.0, ancef Q8H\n\nSKIN: skin intact other than right sided head ventriculostomy drain and left sided head craniectomy wound. vent drain and crani sites covered with DSD, no drainage noted. many old scars on upper arms, upper thighs and abdomen from old selfmutilation habits.\n\nSOCIAL: husband phoned x3 today and was updated on plan and status, friend to visit this afternoon, left numbers for patient's therapist in chart.\n\nplan: continue to monitor neuro exam and ICP level, encourage coughing and deep breathing. continue antibiotic prophylaxis\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-11-26 00:00:00.000", "description": "Report", "row_id": 1514778, "text": "NURSING NOTE 1900-2300\nS/P SAH->VENTRICULAR DRAIN PLACEMENT\n\nNEURO: LETHARGIC BUT EASILY AROUSABLE. FOLLOWS COMMANDS. PERL. EQUAL STRENGTH & SENSATION IN ALL 4 EXTREMITIES. NO SEIZURE ACTIVITY NOTED. NO NEURO SYMPTOMS REPORTED. ICP DRAIN @10 ABOVE THE TRAGUS. ICP15-16.\nICP DRAIN IRRIGATED WITH 4CC STERILE SALINE BY NEURO-. IRRIGATES EASILY. JP DRAIN INTACT & DRAINING SM. AMTS. SERO-SANG DRAINAGE.\n\nRESP: O2->4L NP. BS CLEAR BUT DIMINISHED AT BASES. O2 SAT 96-99%. RR 17-21.\n\nCARDIAC: HR 66-83 SR WITH RARE PVC. BP 121-131/54-67. GOAL IS TO KEEP SBP<140. RECEIVING IV HYDRALAZINE & PO NIMODAPINE. CVP7->14. LR @ 100/\nHR CHANGED TO NS @ 100CC/HR.\n\nGI: TOL. SIPS CLEAR LIXS. ABD. SOFT. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 125-380CC/HR.\n\nID: T 100.7(PO). CONT. ON IV CEFAZOLIN.\n\nPLAN: AGRAM ? IN AM OR FRIDAY. NPO AFTER MIDNOC.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-11-27 00:00:00.000", "description": "Report", "row_id": 1514779, "text": "see carevue:\n angio done today, morphine for pain, confused 1:1 sitter,\n temp 102.2, pan cultures done, med with tylenol, a-line d/c,\n right femoral line d/c no hematoma at site, knee immobiler applied to mtn right leg straight\n\n" }, { "category": "Nursing/other", "chartdate": "2137-11-25 00:00:00.000", "description": "Report", "row_id": 1514773, "text": "patient extubated this evening post craniotomy procedure this AM. Now on 50% face mask,RR 18-20 alert,coop will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2137-11-26 00:00:00.000", "description": "Report", "row_id": 1514774, "text": "t/sicu nursing note 7p-130a\nreview of systems\n\nneuro: pt lethargic but arousable to voice. aox2 and following all commands. equal strength and sensation in all extremeities. pearl. vent drain remains at 10cm above tragus with icp 9-12. vent draining blood tinged csf. dsd to incisional site. conts on dilantin. morphine x2 for c/o pain in head. jp intact draining serosang fluid.\n\ncv: hr 60-80 sr with no ectopy. sbp 110-130 via radial aline which is dampened at times. femoral aline 130-140. cont to go by radial aline which correlates with cuff per sicu ho. +pp with skin warm and dry.\n\nresp: l/s clear and diminished at bases. weaned to 2l nc with sats 95-98%.\n\ngi: remains npo. +bs. conts on protonix\n\ngu: u/o adequate. ivf lr at 75cc/hr.\n\nheme: stable.\n\nendo: bs 110\n\nid: conts on cefazolin to cover drain.\n\nskin: intact.\n\nsocial: husband went home for the night.\n\nplan: cont q1 neuro exams, monitor icps, keep sbp<130, and cont to support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2137-11-26 00:00:00.000", "description": "Report", "row_id": 1514775, "text": "t/sicu addendum\nd/t worsening dampening of radial aline blood pressure will be monitored by femoral aline. labetolol gtt started transciently to keep sbp<130 but presently off.\n" }, { "category": "Nursing/other", "chartdate": "2137-11-26 00:00:00.000", "description": "Report", "row_id": 1514776, "text": "NURSING UPDATE\nNEURO:\n LABETALOL INITIALLY STARTED SHORTLY AFTER TRANSFER TO SICU-A DUE TO FEMORAL A-LINE SBP 170-180, CUFF PRESSURE CHECKED AND NBP CORRELATED TO RADIAL A-LINE, CONCLUSION: FLING/OVERSHOOT ON FEM LINE WAVEFORM. LABETALOL STOPPED AFTER 30MINS AND CURRENTLY MONITORING NBP WHICH HAS REMAINED WITHIN SET PARAMETERS.\n NEUROLOGICALLY INTACT THOUGH LETHARGIC. MORPHINE 4MG IVP X1 FOR C/O HEADACHE WITH GOOD EFFECT, VENTRICULOSTOMY DRAINING PINK TINGED CSF. ALL DATA AS RECORDED ON FLOWSHEETS.\n" }, { "category": "Nursing/other", "chartdate": "2137-11-26 00:00:00.000", "description": "Report", "row_id": 1514777, "text": "Condition Update\nD:See carevue flowsheet for specifics\n Patients tmax 101.2-Dr. orders received to culture. HR stable in NSR rate 70-80 with no ectopy. No gtts required to keep SBP<140-well controlled with scheduled hydralazine (nimodipine also helps to keep BP down). CVP7-12. IVF rate increased to 100cc/hr not taking much as far as PO fluids but making ~200cc/hr of urine.\n Neurologically only deficits noted are that pt is very lethargic, does not always know where she is or the date. Denies any HA did c/o of nauseax1 was given antiemetic with good effect. ICP 8-12 waveform dampened-CSF clearing up. Vent drain @10 above the tragus.\n Husband called for updatex2. Spoke with sister-in-law who requested info but husband was not aware she was calling and does not want any info given to anyone else but himself.\nPLAN:\n Neuro checks\n ?may start HHH therapy tomorrow\n Vent drain @10 above the tragus\n Keep SBP<140\n Notify H.O. with any changes\n" }, { "category": "Nursing/other", "chartdate": "2137-11-28 00:00:00.000", "description": "Report", "row_id": 1514780, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT DOZING ON AND OFF. EASILY ARROUSABLE. ORIENTED X3 WHEN COOPERATIVE WITH EXAM, AT TIMES REFUSING TO ANSWER ORIENTATION QUESTIONS. MAEW. PERRL. IV MSO4 FOR H/A. ICP <20. VENT DRAIN REMAINS AT 10CM/H2O ABOVE TRAGUS WITH CLEAR DRG.\nRESP: LS CTA. O2 WEANED TO 2L. O2 SATS 90 WHEN O2 OFF.\nCV: FEBRILE TO 103. MD INFORMED. TYLENOL GIVEN. BP LABILE. HYPERTENSIVE THIS AM TO 180S, THEN SBP 150S REQUIRING NEO GTT. NEO GTT RESTARTED AND TITRATED TO MAINTAIN SBP 170S. SL DECREASE IN SBP AFTER PO NIMODIPINE AND IV MSO4.\nGI: ABD SOFT. NO BM. C/O GAS PAIN. MIN FLATUS. REGLAN CONTS. TOL CL WITH NO N/V.\nGU: FOLEY INTACT.\nENDO: FSBG COVERED PER RISS.\nPLAN: CONT TO MONITOR NEURO STATUS CLOSELY D/T VASOSPASM RISK. MAINTAN SBP 170S WITH NEO GTT. MAINTAIN PT SAFETY AND 1:1 OBSERVER. CONT PER CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2137-11-29 00:00:00.000", "description": "Report", "row_id": 1514781, "text": "focus update note\nfebrile T max 102.3 no culture per ICU resident, temp decreased to 100.2 with tylenol PRN.\n\ngoal SBP 170s- pt off neo gtt all night. hydralazine PRN for SBP 180-200. at 0300 SBP 200 via aline- ICP 20 for 20 mins- no neurological change noted on exam. ICU and neurosurg resident consulted and pt assessed by both. chief neurosurg resident notified.\n\nneuro: vent drain 10 above tragus, generally ICP transducing , pt alert and oriented X 3 sometimes 2, pt at times not cooperative with exam. pupils consistently 3/3mm brisk bilaterally, mae to command, grips with good strength, dorsiflexion and extension good, no drift noted, pt c/o of h/a periodically level 3 on scale and recieves morphine 2 mg iv with good effect.\n\npt continues to require sitter, pt pulls at lines even with verbal redirection.\n\nplan: continue with HHH therapy\n" }, { "category": "Nursing/other", "chartdate": "2137-12-08 00:00:00.000", "description": "Report", "row_id": 1514798, "text": "Update\nSee carevue flowsheet for specifics\nO: Neuro status: pt a&o x3 vent drain 12cm above tragus open and draining. c/o slt h/a at times med for same w dilaudid po. perl at 3mm brisk. icp-.cvp 1-9 . huo-150-450 cc/hr. ivf at 150cc/hr.w q4h albumin.Continues on neo for goal sbp 160-190 range\nA/P: stable neuro vs. Cont to titrate neo for goal sbp 160-190.Am lab results pending.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-03 00:00:00.000", "description": "Report", "row_id": 1514790, "text": "NEURO: A+OX3, MAE, Speech is clear. Vent drain is 10 at tragus with clear drainage. ICP 4-8. Neo 1.0-2.5mcg for SBP 170-180. CPP 120-150's. Dr. aware no intervention at this time. 1:1 sitter dc's, continue with soft wrist restraints for pt. safety. Odd affect.\n\nCARDIO: NSR with occas PVC's. NEO 1.0-2.0mcg for SBP 170-180. CVP 4-8. No edema. a-line dampens at times. Tmax 101.9, MD aware, no intervention at this time, pt last pan cultured in evening.\n\nRESPIR: clear bil. denies SOB or cough. Smokes about 1ppd per pt.\n\nGI: Soft, round, +bsx4.\n\nGU: Follow with high urine outputs. 3gm Sodium tablets TID started today for NA of 133 with q3hr Na checks.\n\nSKIN: Vent dressing reinforced.\n\nPLAN: Monitor ICP, CVP, Temp's.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-04 00:00:00.000", "description": "Report", "row_id": 1514791, "text": "NPN ( SEE CAREVUE FOR SPECIFICS)\n PT VERY ANXIOUS AT BEGINNING OF THE NIGHT, WANTING TO GET OOB AND LEAVE, YELLING ABOUT \"BEING TIED DOWN\". RESTRAINTS TIED LIGHTLY, GIVING PT A SMALL AMOUNT OF ROM, WATCHED CLOSELY THROUGHOUT THE NIGHT. C/O SEVERE HEADACHE, NEURO SIGNS UNCHANGED, PERRL, MOVING ALL EXT., DR. NOTIFIED AND PT TO CT SCAN. HA RELIEVED WITH DILAUDID 2MG. ICP 4-8. DRAIN DIFFICULT TO MONITOR WITH PT MOVING ALL OVER BED. CONTROLS ON BED LOCKED AND PT MONITORED CLOSELY.\nCV- BP 170-180'S WITH FREQUENT TITRATION OF NEO, BP LABILE. HR 80'S WITH OCCASIONAL PVCS.\nRESP- LUNGS CLEAR, RA.\nGI- TOLERATING POS.\nGU- UOP 200-300CC/HR, SPOKE TO DR. , NO ORDERS TO CHECK SODIUM OVERNIGHT, LABS THIS AM PENDING.\nID- TMAX 101.1, DR. NOTIFIED, TYLENOL GIVEN.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-05 00:00:00.000", "description": "Report", "row_id": 1514794, "text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: A&O X3, SOME INAPPROPRIATE COMMENTS AT TIMES, MAE SPONT/PURP, FOLLOWING COMMANDS, PERL. PT C/O OF WORSENING H/A DESPITE RECEIVING TYLENOL 650MG PO AND DILAUDID 2MG PO W/ LITTLE EFFECT. VENT DRAIN FROM 15CM TO 12CM ABOVE TRAGUS, DR. INFORMED AND PT TO HAVE CTA, ICP 3-12. PT APPEARS MORE COMFORTABLE.\n\nCV: HR 60-70'S, NSR W/ PVC'S, SBP PARAMETERS 170-180, NEO GTT TITRATED ACCORDINGLY.\n\nRESP: LUNG SOUNDS CLEAR BUT DIMINISHED AT BASES. ENC TO DO IS, C/DB.\n\nGI: ABD SOFT NT/ND, + BOWEL SOUNDS, TOLERATING PO INTAKE.\n\nGU: FOLEY DRAINING 150-320CC/HR CLEAR YELLOW URINE.\n\nPLAN: MONITOR VS, LABS, NEURO STATUS. TITRATE NEO GTT TO SBP 170-180. F/U CTA RESULTS.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-06 00:00:00.000", "description": "Report", "row_id": 1514795, "text": " Nsg Progress Note: \"B\"\n\nCVS: T=99.7-97.0 po. HR=56-80 SR with PVC's noted. SBP from 150-200. Titrated IV Neo up and down to try to keep SBP=170-180. Currently IV Neo drip at 3.25mcg/kg/min. IV NS+20meq KCL at 150cc/h. Pharmacy notified to mix all drips in NS. Skin warm and dry. Pulses intact.\n\nResp: No SOB or dyspnea noted.\n\nGI: Pt c/o nausea x2, given anzimetx1 with good effect. Takes diet well. Passing lot of flatus and c/o gas pains but no stool.\n\nGU: U/O=110-775cc/h.\n\nNeuro: Neuros unchanged. c/o of H/A every 1-2hrs, med with Tylenol and Dilaudid as ordered but was not getting relief. Had 1 episode of trying to climb over siderails and tearing off dsgs,clothes and tangling up IV's. Med with Toradolx1 with relief of H/A and pt was calm and cooperative and slept off and on the rest of the night.\nICP=,CVP=. Vent drainage=49cc this shift,clear fluid. Pt constantly picks at head dsg and staples. Reminded her of risk of infection but she only stops picking at them briefly. Stating she \"Wants to get out of here!\"\n\nSkin: No open or red areas noted. No drainage from incision line.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-12-08 00:00:00.000", "description": "Report", "row_id": 1514799, "text": "npn\nPt remains a+o and moves all ext wnl, pearl. Sbp goal 160-180, neo gtt to keep goal. cont agitated at times and refusing some treatment like compression sleeve, na tabs and getting oob to chair. vent drain at 12 above tragus- clear drg. icp 5-9. pt requiring freq reminders not to pull head drsg , at bedside when family not in room. ivf 150hr - .9 with 20 kcl, 0.9 at 60hr started this am. Lg bm this am, while oob on commode c/o \"dizzy\" sbp 157, hr 70's, while being assisted back to bed knees buckled, but pt did not fall- lowerd to sitting position on floor. Pt began crying- assisted back to bed, sbp 200 in bed with neo gtt at 4mcg/kg/min. (neo gtt lowered). stool guiac neg, lytes sent- all wnl. Md - Dr - notified of event.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-09 00:00:00.000", "description": "Report", "row_id": 1514800, "text": "condition update\nD: pt is alert and oriented follows commands. pupils equal and reactive to light. no drift noted. normal strength in all extremuties, c/o worst headache of life. seen by DR. no change in neuro status. stat head ct done with no change. pt treated with 500cc of ns and 6mg of deacdron and 2mg of dilaudid with relief. headache diminished and pt able to sleep. no change in neuro status. icp remains and continues to drain clear csf. neo titrated for sbp 160-180. pt noncompliant in keeping bp cuff on and refusing checks. cvp is . dr. aware and no further fluid bolus. urine output is 160-400 cc/hr. pt takine in large amts of po fluid. pt refusing compression sleeves and sodium tabs..\na: continue with neuro checks. pt reminded to no change head level due to drain. pt reminded not to touch drain dressing. head controls locked out of bed to keep tragus level with vent drain.\nr: neo titrated for sbp 160-180. neuro is intact. headache diminished after dilaudid and decadron. no further fluid boluses at this time. pt continues to refuse certain therapies.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-04 00:00:00.000", "description": "Report", "row_id": 1514792, "text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: PT A&O X3, SOME INAPPROPRIATE COMMENTS BUT ORIENTED FOR THE MOST PART. MAE SPONT/PURP, FOLLOWING COMMANDS, PERL. VENT DRAIN INC FROM 10CM TO 15CM ABOVE TRAGUS, W/ CLEAR FLUID, ICP 3-9. C/O OF H/A, MEDICATED W/ TYLENOL 650MG PO AND DILAUDID 2MG PO W/ GOOD EFFECT.\n\nCV: HR 64-82, NSR W/ PVC'S. SBP PARAMETERS 170-180'S, NEO GTT TITRATED ACCORDINGLY.\n\nRESP: LUNG SOUNDS CLEAR, NO SOB.\n\nGI: ABD SOFT, NT/ND, + BOWEL SOUNDS, TOLERATING GOOD PO INTAKE. NO N/V.\n\nGU: FOLEY DRAINING LRG AMT CLEAR YELLOW URINE.\n\nPLAN: MONITOR VS, LABS, NEURO STATUS. CONT W/ 1:1 SITTER. TITRATE NEO. CONT CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-05 00:00:00.000", "description": "Report", "row_id": 1514793, "text": " Nsg Progress Note: \"B\"\n\nCVS: T102.4-101.2 po. HR=69-100 SR with rare to occ PVC's. SBP=143-205. IV Neo drip titrated to 3.5mcg/kg/min. Aline d/c'd due to infiltration. IV NS+20meq KCL at 125cc/h. Pulses intact.\n\nResp: Lungs clear, no problems.\n\nSkin: No open areas. Incision line on head clean and dry. Pt constantly picking at drain dsg.\n\nNeuro: c/o headaches whenever anyone does care or tries to do any procedure with pt. Given dilaudidx4 this shift. Very agitated and anxious, shaking and swearing at 6am with aline attempt. Pt would not allow line insertion to be accomplished. CVP=,ICP=. Vent drain=90cc this shift.\n\nGU: U/O=160-870cc/hr.\n\nGI: No c/o, +bowel sounds.\n\nPlan: Pt was seen by Psych last eve. Pt states he says she can have Ativan but did not ordered it or tell anyone else. Resident will check during rounds to get order for ativan at least to insert the aline.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-06 00:00:00.000", "description": "Report", "row_id": 1514796, "text": "NPN\nSee carevue for details and remarks::\n\nNeuro: Alert, oriented. Odd affect. Pupils equal, reactive. Ventric drain @ 12cm (H2O) above tragus, draining clear CSF. Head sutures clean, dry, intact. Complaints of headache, +relief w/dilaudid PO. ICP 3-8. 1:1 sitter for safety purposes.\n\nResp: Lungs clear, diminished @ bases, O2 sat98-99%.\n\nCV: On neo gtt, to keep SBP 170-180. HR 60-70s. R CVL, IVF-NS w/20K@ 150. CVP 8-13. Noncompliant w/BP, SVO2 monitoring, SICU and Neuro team aware.\n\nGI: On house diet, appetite poor. Abd soft, nontender, +BS.\n\nGU: Foley draining clear yellow urine, copious amts per hour.\n\nSocial: Husband calls to check on pt prn.\n\nPlan:Cont to keep BP 170-180, titrate neo as needed. Monitor ventric drain, ICP, MS. intake. Encourage OOB. Maintain 1:1 sitter for safety.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-12-07 00:00:00.000", "description": "Report", "row_id": 1514797, "text": "npn\n Pt is A+O x3 and moves all ext wnl. pearl, c/o ha, rx with dilaudid po prn. vent drain at 12 above tragus, clear drg. icp 1-6, cvp 4-8. ivf 150hr, neo gtt to keep sbp 160-180. cvp 4-8. albumin 25gm iv q4.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-01 00:00:00.000", "description": "Report", "row_id": 1514786, "text": "npn\n Pt is a+o and moves all ext wnl, tol up to chair this am, after return to bed sbp decrease to 130's, sicu md and neuro md aware. Multi fluid bolus given. neo gtt restarted to keep sbp >160. cvp 5-9. icp 6-11. vent drain 10 above tragus, small amounts clear drg. denies ha.\n\nGi_ tol house diet, + bs, last bm .\n\nID_ temp max 101.2, pan cx this am, cont ancef tid.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-02 00:00:00.000", "description": "Report", "row_id": 1514787, "text": "focus update\nfebrile t max 102.4 icu resident aware no panculture - as pt was cultured within the last 24 hours. tylenol given with effect heart rate 80s-90s, goal sbp 160-180- bp very labile requiring neo gtt periodically and hydralazine X 1.\n\nneuro- unchanged no complaint of headache, a+oX3, mae, follows commands consistently, pupils 3/3mm brisk- no drift, vent drain continues at 10cm h2o above the tragus, clear csf drainage, requires 1:1 sitter for continued periods of poor decision making ie pt attempting to get oob without help, and pulling at IV lines. head dressing intact.\n\nplan: continue to moniotr neuro status- keep sbp 160-180\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2137-12-02 00:00:00.000", "description": "Report", "row_id": 1514788, "text": "Neuro: A&O, sleeps in naps, mae with equal strength, perrl. Vent drain 10>tragus draining clear csf at 10cc q 2-3hrs. HA x1 medicated with tylenol to effect. Dressing at drain intact. Pt does continue to require 1:1 superivsion/soft wrist retraints in order not to manipulated vent drain and other equipment/lines. CV: Remains on/off neo to keep sbp 160-180. Aline postitional, order recieved to initiate albumin q6hr for cvp 4-5. Lytes checked a occ/freq pvc's this afternoon K=4.3, Mag=2. Qrs complexes noted in cvp wave form, team to check cxr for postion of central line. Pulm: Lungs clear, 02 sats on RA 99-100%. GU: UO >200cc/hr clear yellow urine. GI: Abd soft, bs+, pt passing flatus. Pt taking house diet with fair appetite. Skin: Surfaces intact, peripheral pulses present. Staples at craniotomy site d&i. Endo: Per ssc. Soc: Husband phoned x2. P: Continue to monitor neuro status, titrate neo gtt for parameters. Notify team of more frequent ectopy, ?need to pull back line. Keep family up to date on plan of care. R: Team to pull back line, neo gtt currently at .5mcg/kg/min, husband will be in to visit this pm. All else as above.\n" }, { "category": "Nursing/other", "chartdate": "2137-12-03 00:00:00.000", "description": "Report", "row_id": 1514789, "text": "SAH day#9 positive vasospasm\nNeuro:Pt disoriented to time(year) intermittently. Once pt stated she was in . PERRLA. MAE equally, follows commands.Pt putting rt leg over side rail \"I am getting up. \" Ventricular drain @ level 10-tragus. ICP5-7 (want5-8).PA in to examine ventricular drain which had ceased draining(patent per PA when it was checked).\nTemp 102 PA sent CSF fluid for c&s. 1 fluid bolus NS 500ml given and albumin increased to 25 gm q6hr per Dr in response to out of range SBP down and CVP<5 out of wanted range.\nCV:SR with occasional PVCs. 1 episode of sinus bradycardia while pt was sleeping SBP increased to 220 at that time neo off shortly, HR and SBP returned to baseline.\nResp:1 episode not related to above where pt dropped O2Sat to 91%. O2 2LNP started. Spirometer used. Lungs clear.\nGI:Drinking gingerale. No c/o N/V. BS present.\nGU:Urine output picked up 300-400/hr. Neuro PA notified. Urine and serum osmo sent. Na/K sent.\nPlan:Continue HHH therapy.\n Safety issues, continue sitter please.\n \n" }, { "category": "Nursing/other", "chartdate": "2137-11-24 00:00:00.000", "description": "Report", "row_id": 1514769, "text": "Nsg Admission Note\nMs. is a 43yo female admitted to TSICU as a NSICU pt with diagnosis of SAH. PMH/PSH significant for ?HTN, lap chole, depression, self-mutilating behavoirs in past (cutting). Pt takes Ativan, unknown psych med. PTA she had been at home with husband, reported to have had a \"couple\" of cocktails, went to bed. During night husband noted pt was \"breathing funny\", brought pt to OSH. Pt given Narcan with little to no effect. Pt c/o headache, CT revealed diffuse SAH, pt trans to for further treatment. In pt loaded with Dilantin, vent drain placed, R rad A-line placed, started on Nipride. No seizure activity noted. Further imaging in ED showed SAH, trans to SICU.\nCURRENT STATUS:\nSee carevue for subjective/objective data.\nNeuro: Pt arousable to speech, oriented to self only. PERL, 3mm, brisk. R hand grasp strong but not equal to L; L hand grasp very strong. R foot movement weak, L foot movement strong. Pt c/o numbness middle, 4th and 5th toes R foot and along R side of foot to ankle, c/o tingling R baby finger and side of hand to wrist. No numbness or tingling anywhere else. Pt also c/o headache and photosensitivity. No seizure activity noted.\n\nCV/Pulm: MP=SB-SR, no ectopy noted. Nipride titrated to maintain SBP<130; Nipride at 3mcg/kg/min when pt trans to angio with SBP hovering at 125-131. NP at 2l with sats 98%. BS clear bil. No SOB, no DOE noted.\n\nGI/GU: pt c/o nausea, vom x1. Med with Azomat and Reglan. U/O qs via foley.\n\nID/access: Afebrile. Will start on abx. Nipride as noted. Periph IV x3 in place, R rad A-line.\n\nPsychosocial/Plan: No visitor with pt at this time. Emotional support given to pt. Plan is to sent pt to angio; pt is in angio at this time.\n" }, { "category": "Nursing/other", "chartdate": "2137-11-25 00:00:00.000", "description": "Report", "row_id": 1514770, "text": "Nursing Progress Note\nS/ Pt returned from OR S/P aneurysm clipping.Pt was intubated and ventilated with #7 ET tube. Pt had arterial sheath in rt groin to pressure bag, Rt arterial radial line, Rt subclavian triple lumen catheter. Nad 4 perepheral IV's both rt and lt arms. Foley to gravity and oral gastric tube to gravity.pt had ventriculostomy drain in place at 10 above the tragus , to drainage.\n pt initially paralysed and sedated, propofol stopped and pt was reversed by anesthesia,pt was able to nod, open eyes and moved all fours inconsistently to command with good strength. PERL. Gag and cough intact. Pt was resedated with propofol,titrated up to 100 mcg/kg/min to keep pt sedate and attemtp to control rising ICP , of 25-30. Ventriculostomy was irrigated and was draining blood tinged CSF. pt was given Fentanyl, 50 to 75 mcg/hr for sedation. Mannitol was given x2 for increasing ICP, pt emergently sent to CT scan and then to OR for elevated ICP of 30-40. Pt had spontaneous purposeful movement of all extremities throughout the night, pupils remained at 3 and reactive.\n pt initially hypertensive, was transiently on Nipride for B/P control, weaned off once pt resedated. B/P 100-120/50-60. HR 70-90's NSR with frequent ectopy. lytes repleted. Hct this AM 28.3. CVP- .\n pt ventilated on SIMV 600x14 with 5 peep, 50% FIO2. pt suctioned for small amt of thick tan secretions, breath sounds clear. CXR done\n pt has oral gastric tube in place to suction draining green bile, pt initially vomited around tube when she was reversed. abd is soft with bowel sounds .\n pt had adequate urnie output, pt received lasix 10mg IVP and mannitol with good diuresis.\nendo- FS was 1112 and pt did not require coverage.\n pt tempt 97 on admission warmed to a temp of 100.2, pt receiving cefozolin for antibiotic coverage.\nskin- intact on back and buttucks, head dressing intact with no drainage.\nA/ pt cont to have rising elevated ICP , requiring sedation, mannitol,lasix and OR intervention. Cont with plan of care per team.\n\n" }, { "category": "Nursing/other", "chartdate": "2137-11-25 00:00:00.000", "description": "Report", "row_id": 1514771, "text": "pt's ICP were increasing therefore pt brought to CT and then OR.\n" }, { "category": "Radiology", "chartdate": "2137-11-24 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 845937, "text": " 6:32 AM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: SUBARCHNOID HEMORRHAGE, ASSESS FOR ANEURYSM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with sub-arachnoid hemorrhage\n REASON FOR THIS EXAMINATION:\n assess for aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ESE SUN 10:20 AM\n Acomm-left A1 aneurysm.\n Extensive subarachnoid hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Subarachnoid hemorrhage, possible aneurysm.\n\n TECHNIQUE: Noncontrast axial images of the head were obtained. These were\n followed by thin-sliced contrast-enhanced images. Multiplanar reformatted\n images were obtained.\n\n COMPARISON: None.\n\n HEAD CTA: There is a 3 mm x 4 mm saccular aneurysm at the junction of the A1\n and ACOM segment on the left side. The right anterior cerebral artery is\n supplied entirely by the anterior communicating artery. No A1 segment is seen\n on the right. Normal flow is seen within the other vessels of the circle of\n . There is normal flow within the vertebral arteries and within the\n carotid arteries.\n\n HEAD CT W/O & W/IV CONTRAST: There is extensive subarachnoid hemorrhage\n within the brain extending along the falx and across the base of the brain.\n There is a diffuse sulcal narrowing. There is a ventricular drainage catheter\n which enters the right frontal lobe, and terminates with tip in the frontal\n of the right lateral ventricle. The ventricles are not dilated. There\n is hemorrhage layering within the posterior horns of the lateral ventricles.\n There is no shift of normally midline structures. The /white matter\n differentiation is unremarkable. The osseous structures, mastoid air cells,\n and visualized paranasal sinuses are unremarkable.\n\n CT RECONSTRUCTIONS: Multiplanar reformatted images confirm the above-\n mentioned findings.\n\n IMPRESSION\n\n 1. Saccular aneurysm at the branch of the left A1 segment and anterior\n communicating artery.\n\n 2. Extensive subarachnoid hemorrhage with mild diffuse sulcal narrowing.\n (Over)\n\n 6:32 AM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: SUBARCHNOID HEMORRHAGE, ASSESS FOR ANEURYSM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2137-11-24 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 845949, "text": " 10:14 AM\n CAROT/CEREB Clip # \n Reason: eval/coiling aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 116\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID UNILAT VERT/CAROTID A-GRAM *\n * EXT UNILAT A-GRAM -52 REDUCED SERVICES *\n * C1769 GUID WIRES INFU/PERF C1892 INT/SHTH EP FXD CURVE/PEEL AWY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with subarachnoid hemorrhage, ? ACOM aneurysm\n REASON FOR THIS EXAMINATION:\n eval/coiling aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage.\n\n POSTOPERATIVE DIAGNOSIS: Same. Ruptured 8 x 4 mm anterior communicating artery\n aneurysm.\n\n INDICATIONS: Ms. is a 43-year-old female who was noted the night\n before this exam to be somnolent and unarousable after drinking several\n glasses of wine. She was taken by her husband to an outside hospital where a\n CAT scan revealed the presence of a diffuse subarachnoid hemorrhage and the\n presence of an interhemispheric clot between the frontal lobes. CTA was\n performed upon arrival at this institution following the placement of an\n external ventriculostomy catheter. This CTA angiogram demonstrated the\n presence of a large anterior communicating artery aneurysm. She undergoes this\n exam to evaluate for potential of coil embolization and to further delineate\n the anatomy of this lesion.\n\n CONSENT: The patient's husband was given a full and complete explanation of\n the procedure. Specifically, the indications, risks, benefits, and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications, including the risk of coma and even death, were outlined. The\n patient's husband understood and wished to proceed with the operation.\n\n ANESTHESIA: General endotracheal anesthesia.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial blood, a 4 Fr vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next, a diagnostic catheter was used to\n (Over)\n\n 10:14 AM\n CAROT/CEREB Clip # \n Reason: eval/coiling aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 116\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n selectively catheterize the following vessels: left subclavian artery, left\n vertebral artery, left common carotid artery, left internal carotid artery,\n left external carotid artery, right common carotid artery.\n\n RESULTS: Injection of the left common carotid artery demonstrates it to be\n free of stenosis or dissection and injection of the left internal carotid\n artery demonstrated a normal cervical course. Intracranially, there is a\n dominant left A-1 segment with a multilobulated 8 x 4 mm aneurysm with an\n approximately 3.5 to 4 mm neck arising from the A1-2 anterior communicating\n artery junction which is wide necked in appearance. The anterior communicating\n artery provides the dominant flow to the right ACA, and additionally flow is\n seen throughout both ACA territories and no evidence of vasospasm is\n appreciated. The left ICA also contributes to the left MCA and PCA territories\n via a left posterior communicating artery. No other intracranial aneurysms are\n identified. There is no other intracranial stenosis or dissection. Injection\n of the left external carotid artery demonstrates a normal cervical branching\n pattern without evidence of abnormal fistulous connection to the intracranial\n circulation. Injection of the left subclavian artery demonstrates\n normal appearance of the vessel itself and a smooth appearance of the origin\n of the left vertebral artery, and injection of the left vertebral artery\n demonstrates a normal cervical course. Contrast reflux is seen into the right\n vertebral artery and no evidence of intracranial aneurysm of the\n vertebrobasilar system is appreciated. The right PICA was visualized from this\n injection. Note is made of bilateral duplicated superior cerebellar arteries.\n Injection of the right common carotid artery demonstrates a smooth cervical\n course with a smooth-appearing carotid bifurcation and visualized portion of\n the cervical and cavernous carotid artery without stenosis or dissection, and\n there is additionally no note made of any intracranial aneurysm. At this point\n the examination was concluded, and the patient was transferred emergently to\n the operating room for craniotomy for clipping of the aneurysm.\n\n IMPRESSION: Ruptured anterior communicating artery aneurysm as described\n above.\n\n\n\n\n\n\n\n\n\n (Over)\n\n 10:14 AM\n CAROT/CEREB Clip # \n Reason: eval/coiling aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 116\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2137-11-27 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 846260, "text": " 8:43 AM\n CAROT/CEREB Clip # \n Reason: evaluate post clipping\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 156\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * VERT/CAROTID A-GRAM EXT BILAT A-GRAM *\n * -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with subarachnoid hemorrhage, ? ACOM aneurysm\n\n REASON FOR THIS EXAMINATION:\n evaluate post clipping\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage status post clipping of\n anterior communicating artery aneurysm.\n\n POSTOPERATIVE DIAGNOSIS: Same with no identified aneurysmal remnant.\n\n INDICATION: Ms. is a 43 year old female who is noted previously to\n have a subarachnoid hemorrhage from a ruptured anterior communicating artery\n aneurysm approximately 8 x 4 mm in size. Previous angiography demonstrated\n this as well as the morphology of the aneurysm which rendered it uncoilable.\n She was taken for a left-sided craniotomy for clipping of this aneurysm.\n Presents today for post clipping angiography to access clip placement\n aneurysmal remnant and the presence of vasospasm.\n\n CONSENT: The patient and the patient's husband were given a full and\n complete explanation of the procedure. Specifically, the indications, risks,\n benefits and alternatives to the procedure were explained in detail. In\n addition the possible complications such as the risk of bleeding, infection,\n stroke, neurological deficit or deterioration, groin hematoma, and other\n unforeseen complications including the risk of coma and even death were\n outlined. The patient and the patient's husband understood and wished to\n proceed with the operation.\n\n ANESTHESIA: Conscious sedation.\n\n PROCEDURE IN DETAIL: The patient was brought in the endovascular suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19 gauge single wall needle was then\n used to puncture the right femoral artery and upon the return of brisk\n arterial blood, a 5 FR vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next a diagnostic catheter was used to\n selectively catheterize the following vessels over a guidewire in succession:\n Right subclavian artery, right vertebral artery, right common carotid artery,\n (Over)\n\n 8:43 AM\n CAROT/CEREB Clip # \n Reason: evaluate post clipping\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 156\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right internal carotid artery, left common carotid artery, left internal\n carotid artery, left subclavian artery.\n\n RESULTS: Injection of the right subclavian artery demonstrates\n normal anatomy of the vessel itself and takeoff of the right vertebral artery.\n The right and left vertebral arteries contributes flow to the basilar artery\n and PCA territories bilaterally. The origin of the right vertebral artery is\n smooth cervically and intracranially and is free of stenosis, dissection, or\n aneurysm. Mild vasospasm is noted within the right posterior cerebral artery\n proximal P1-2 segment. Otherwise, no intracranial aneurysm is identified.\n Injection of the right common carotid artery demonstrates a smooth cervical\n course without evidence of stenosis or takeoff. It is somewhat high in\n tortuous origin of the right internal carotid artery. Injection of the right\n internal carotid artery demonstrates a normal cervical petrous intracranial\n course. Flow contribution is seen to the right MCA and PCA territories via a\n prominent right posterior communicating artery. No intracranial aneurysm is\n identified. The right A1 segment is hypoplastic. No evidence of intracranial\n vasospasm is identified. Injection of the left common carotid artery\n demonstrates a normal cervical course with a smooth appearing carotid\n bifurcation. Injection of the left internal carotid artery demonstrates a\n normal cervical and intracranial course. The aneurysm clip positioning is\n noted on biplane fluoroscopy and on contrast injection good opacification of\n the dominant left A1 bilateral distal ACA segments is noted. There is no\n parent vessel stenosis at the site clip placement and initially no aneurysmal\n remnant is seen. No other intracranial aneurysms are identified and there is\n no evidence of branch occlusion throughout the left MCA, left ACA, and right\n ACA territories. Injection of the left subclavian artery demonstrates\n normal anatomy of the vessel itself and a smooth takeoff of the left vertebral\n artery. At this point, the examination was terminated due to patient motion.\n\n IMPRESSION: Cerebral angiogram post clipping of anterior communicating artery\n demonstrates good clip position without evidence of aneurysmal remnant mild\n vasospasm observed the posterior cerebral artery territories.\n\n\n\n\n\n\n\n\n\n (Over)\n\n 8:43 AM\n CAROT/CEREB Clip # \n Reason: evaluate post clipping\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 156\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2137-12-05 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 847122, "text": " 5:47 PM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o vasospasm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman s/p clipping acom aneurysm, decompressive craniectomy\n REASON FOR THIS EXAMINATION:\n r/o vasospasm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post ACOM aneurysm clipping and decompressive craniectomy,\n rule/out vasospasm.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without intravenous contrast. Following this, arterial enhanced multi-\n detector CT images of the head were obtained. 100 cc of Optiray contrast were\n administered. Thin sliced and multiplanar reformatted images were obtained.\n\n COMPARISON: head CT, and head CTA.\n\n HEAD CTA: There is flow within the internal carotid arteries, vertebral\n arteries, and basilar artery. And there is opacification of the major\n branches of the circle of . Metal artifact is present in the region of\n the anterior communicating artery, consistent with aneurysm clipping. Flow is\n seen within the anterior cerebral arteries bilaterally. The caliber of the\n vessels is grossly unchanged in comparison to the prior study.\n\n HEAD CT W/O & W/IV CONTRAST: A small amount of blood is present layering\n within the lateral ventricles. There are no new foci of high attenuation to\n suggest acute hemorrhage. The ventricles are not dilated. There is a\n ventricular drainage catheter which traverses the right frontal lobe, and\n terminates with the tip in the frontal of the right lateral ventricle.\n There is no shift of normally midline structures. The patient is status-post\n left frontal craniectomy. There is a low attenuation fluid collection outside\n of the brain within the craniectomy site. The cisterns are patent. The\n /white matter differentiation is preserved. The mastoid air cells and\n visualized paranasal sinuses are unremarkable. No abnormal enhancing lesions\n are present.\n\n IMPRESSION\n\n 1. Flow within the internal carotid arteries, basilar artery, and\n major branches of the circle of . The accuracy of CTA, compared to\n angiography, for the assessment of vasospasm following subarachnoid\n hemorrhage is unclear.\n\n 2. Post-operative changes in the right skull without evidence of new\n hemorrhage or mass effect.\n\n (Over)\n\n 5:47 PM\n CTA HEAD W&W/O C & RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o vasospasm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2137-11-25 00:00:00.000", "description": "Report", "row_id": 284723, "text": "Probable sinus rhythm. Low limb lead voltage. Since the previous tracing\nof no significant change.\n\n" }, { "category": "ECG", "chartdate": "2137-11-24 00:00:00.000", "description": "Report", "row_id": 284724, "text": "Sinus rhythm\nLong QTc interval\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 1547306, "text": "S: \"CAN I HAVE THE BUCKET, I'M GOING TO BE SICK\"\nO/A: PT A/O FEELING NAUSEATED MOST OF SHIFT. AT 915P C/O ABD DISCOMFORT GIVEN 2 TYLENOL PPR, HO AWARE, SOME RELIEF, PT ASLEEP AGAIN. AT 2340 PT REPORTED FEELING SICK VOMITED DK GREEN HEME POS BILE 30CC, THEN BACK TO SLEEP, PT GIVEN ZOFRAN WITH SOME EFFECT. PT AWOKE AROUND 3A VOMITED ANOTHER 40-50CC DK GREEN BILE, THEN BACK TO SLEEP, DURING THESE TIME REPOSITIONG ALSO TRIED FOR PT COMFORT.\nCV: SB 50'S NO ECTOPY NOTED, BP 76-115/40-70, DOPAMINE BEG OF SHIFT UP TO 5MCQ NOW WEANED TO 3 , PTG TOLERATING WELL. INTEGRILLIN GTT 1 STILL PT DENIES ANY CARDIAC SX\nRESP: PT WEANED OFF O2 98% RA, DENIES SOB, LUNGS CLEAR, OCC\nGI: PT CONTINUES WITH ABD DISCOMFORT AND C/O LOWER BACK PAIN HEATING PAD APPLIED AND PT WITH GOOD EFFECT PT BACK TO SLEEP, POS BS\nGU: PD DONE AT 730P, 300 NET OUT, 1130P - , PT TOLERATING WELL, PT WAS INCONTINENT SM AMT X 1 WITH VOMITING.\nSKIN: R GROIN SHEATH STILL PRESENT FOR LINE AXIS AND ALINE CAPABILITIES. GROIN SITE SCANT AMT OLD BLOODY DRAINAGE NOTED\n" }, { "category": "Nursing/other", "chartdate": "2133-09-07 00:00:00.000", "description": "Report", "row_id": 1547304, "text": "CCU NURSING PROGRESS NOTE\nS:\"I DON'T HAVE ANY MORE PAIN\"\n\nO:PT ADMITTED FROM ER W/ C/O CP, PT WAS HYPOTENSIVE AND PLACED ON DOPA. PT ARRIVED CP FREE. DOPA AT 8MCG/KG/MIN ATTEMPTED TO WEAN DOPA TO 5MCG PT BECAME HYPOTENSIVE W/ SBP 70S. DOPA TITRATED BACK UP TO 8MCGS. SEE FLOW SHEET FOR VS. PT WITHOUT CENTRAL LINE. LINE ATTEMPTED AT RIGHT SUB CLAVIAN SITE IN ER. PT OOZING FROM PUNCTURE SITES. HEMATOMA PRESENT. PRESSURE APPLIED. DR. NOTIFIED. PRESSURE DSG APPLIED. OLD FISTULA SITE IN LEFT ARM ,NOR BP OR STICKS. TWO PERIPHERAL IVS ON RIGHT PATENT. MHR SR NO VEA. SKIN PINK WARM AND DRY. LUNGS CLEAR. SATS >95 ON 4L. GI: PT OBESE ,+BS AND HYPOACTIVE. RENAL: PT ARRIVED DWELLING, DRAINED 2.5L OF CLR YELL EFFLUENT, NO FIBRIN STRANDS VISABLE. TOTAL DRAINAGE REPORTED TO RENAL FELLOW. PT NOW DWELLING SINCE 0400 W/ 2.5% PERITONEAL DEXTROS EXCHANGE.GU: PT VOID VERY LITTLE. FAMILY IN BRIEFLY, UNIT PHONE NUMBER GIVEN. ENDO:GLU 116.\nA/P:PT W/ UNSTABLE ANGINA, R/O MI. PT FOR CATH TOMORROW. CONTINUE PERITONEAL DIALYSIS 5 EXCHANGES PER DAY. NPO TO NOC. ATTEMPT TO WEAN DOPA OFF AS TOL OR ATTEMPT CENTRAL LINE INSERTION.\n" }, { "category": "Nursing/other", "chartdate": "2133-09-07 00:00:00.000", "description": "Report", "row_id": 1547305, "text": "CCU Progress Note:\n\nO- see flowsheet for all objective data.\n\ncv- cardiac cath done today- Tele: SR no ectopy- HR 59-64- R arterial sheath to transducer- B/P 80-112/44-54 on dopamine gtt- beginning to wean off- Pt SBP normally runs 80-90's- Con't on integrilin gtt @ 1mcq/kg/min- R groin without oozing or hematoma- feet = cool to touch with weak palpable DP & PT pulses- (+) pulses also confirmed with doppler- Hct 34.9- K 4.6- repeat labs due @ - R subclavian area pressure dsg D&I (unsuccessful attempt to insert CL).\n\nresp- In O2 3L NC- ABG's done in cath lab 7.31-44-100- lung sounds diminished @ the bases- SpO2 96-100%.\n\nneuro- A&O X3- moving all extremities- cooperative- follows command.\n\ngi- abd soft (+) bowel sounds- peritoneal cath dsg intact- no BM today taking Po flds without incident.\n\ngu- peritoneal dialysis- 2.5% dextrose exchange 5X/day- Presently, dwelling- scheduled to drain @ 1900 X 15-30min- then instill dialysate\nuntil bag empty- cap peritoneal cath & dwell X4 hrs, then repeat- drained 2800cc @ 9am before cath- BUN 41 Crea 7- (Pt does void, but very little- HNV this shift).\n\nid- afebrile- WBC 15.9- cultures pending.\n\nA- S/P cardiac cath- severe native LCx/OM disease, moderate in-stent restenosis in the SVG to OM, LIMA to LAD and SVG to RCA patent- successful PTCA/stenting of the LCx/OM\n\nP- Wean dopamine gtt off- con't integrilin gtt @ 1mcq/kg/min- draw labs @ as ordered- monitor vs, lung sounds, I&O, & labs- Do not use L arm for blood draws &/or B/P ( L arm fistula )- peritoneal dialysis as ordered 5X/day- offer emotional support to Pt & family-\nkeep them updated on plan of care.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 1547307, "text": "CONT'D FROM ABOVE: GROIN SITE SMALL ECCHYMOTIC AREAS UNCHANGED FROM BEG OF SHIFT BUT SIFE FEELS MORE FIRM THAN THE BEG OF SHIFT DOPPPLE ALL PULSES LEG WARM. R CHEST PRESSURE DSG INTACT FROM UNSUCCESSFUL LINE PLACEMENT.\nPLS SEE FLOW SHEET FOR REST OF ASSESSMENT AND SPECIFICS. CONT WITH PD 5X/DAY, FSBS QID NEXT AT 0600, LABS DRAWN AT 0400, MONITOR HCT AND CK/MB, K+, SEE FLOW SHEET FOR VALUES. SHEATH WILL BE PULLED TODAY CONT TO WEAN DOPA\n" }, { "category": "Nursing/other", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 1547308, "text": "7 AM TO NOON PT CO PAIN IN ABD,BOTH GROINS ,BACK AND CHEST, EKG UNREMARKABLE .ALSO VOMITING GREEN BILE.PHENERGEN CAUSED CONFUSION .VOMITING FINALLY CONTROLLED C 6MG OF ZOFRAN .PAIN FREE AND ABLE TO TAKE MEDS SINCE NOON .NOW ALERT/ORIENTED .\n\nSR TO SB NO ECTOPY .MAP AT GOAL 50S BY ALINE ,DOPAMINE DC 11 AM.MAP 40S BY CUFF. FEMORAL SHEATHS DC, ECCHYMOSES UNCHANGED .PULSES BY DOPPLER. OOZING AT R SUBCLAVIAN STOPPED AFTER PRESSURE . HCT 28 ,TO GET BLOOD TRANSFUSSION .MG REPLETED .\n\nSAT 98 ,RM AIR .\n\nTOL CLEARS PO .ABD SOFT ,GIVEN LAXATIVE .\n\nNO URINE .1 TO 2 LITERS OFF PER DIALYSIS EXCHANGES .\n\nIMPROVED\n\nZOFRAN PRN FOF NUASEA\nCONTINUE PD\n" }, { "category": "Nursing/other", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 1547309, "text": "CT SCAN DONE ,RETRO PERITONEAL RO.\nABLE TO TAKE SMALL AMT DINNER\n" }, { "category": "Nursing/other", "chartdate": "2133-09-09 00:00:00.000", "description": "Report", "row_id": 1547310, "text": "\"I ache all over\"\nptlying in bed very sleepy most of shift but easily arousable. pt reports feeling \"wiped out\". at 8p prbcs infusing slowly ending 1 unit at 930p, pd done at 8p and 12mn and 4a see flow sheet for specifics of shift. pt tolerated blood well. At 1130p pt off bedrest, pt oob 2 assist for guidance to chair. Pt transferred well, reported feeling \"woozy\" and \"weak\" but did msot of the work herself. Pt sat up until 0130. Pt c/o mostly of back pain and then generalized aches and pains.\npt repositioned, medicated with tylenol and given heating pad with good effect, pt back asleep.\ncv: sr 60's no ectopy, maps 50-60\nresp: ra sats 98-100%, lungs with few faint crackles bibasilar.\ngi: abd soft, hypoactive bs, pd site abd wnl. pt given po bisacodyl\ngu: pt hnv this shift.\npt noted for resolving ecchymotic area r chest, no drainage also r groin site unchanged ecchymotic with dsd, pos pulses by doppler. pt down to # 22 in r hand for access, unable to get 0100 labs ho aware.\n" }, { "category": "Radiology", "chartdate": "2133-09-11 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 798590, "text": " 9:34 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ABD.PAIN\n Admitting Diagnosis: CHEST PAIN,HYPERTENSION\n Field of view: 47\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with hypotension, abd pain, and on peritoneal dialysis. Was\n on dopamine. Concerned re:recurrent ab pain, possible mesenteric ischemia due\n to poor perfusion.\n REASON FOR THIS EXAMINATION:\n ?Mucosal thickening c/w mesenteric ischemia? Please use oral contrast only, if\n indicated.\n CONTRAINDICATIONS for IV CONTRAST:\n poor renal function; please use po contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITHOUT IV CONTRAST\n\n INDICATION: Hypotension, abdominal pain and peritoneal dialysis.\n\n TECHNIQUE: Helically aquired images through the abdomen and pelvis with oral\n but no IV contrast.\n\n Comparison is made to a study of three days previously.\n\n CT ABDOMEN W/O IV CONTRAST:\n\n There is atelectasis at the lung bases. There are coronary artery\n calcifications.\n\n There is fatty infiltration of the liver with some sparing around the gall\n bladder. There is ascites, consistent with patient's peritoneal dialysis.\n There is a slightly increased amount of free air within the abdomen which is\n likely due to recent dialysis. Vicarious excretion of contrast is seen within\n the gallbladder and two filling defects are again seen, representing\n gallstones. There is no interval biliary dilatation. Stranding is again seen\n around the head of the pancreas. There is decreased fluid in the anterior\n para-renal space.\n\n Noncontrast views of the pancreas and spleen are normal. The native kidneys\n are atrophic and calcifications are seen within each. There is no abnormal\n mesenteric or retroperitoneal adenopathy.\n\n CT PELVIS W/O IV CONTRAST: The bowel is well visualized. There are no areas\n of bowel wall thickening to suggest ischemia. There is no dilatation of the\n bowel. No air is seen within the bowel wall or the mesenteric vasculature.\n Delayed excretion of contrast from prior CT exam is seen within the bladder.\n Near the umbilicus there is a small subcutaneous air and fluid collection.\n Previously, subcutaneous stranding was seen within this area. The collection\n measures 10 x 8 mm.\n\n The osseous structures are unchanged.\n (Over)\n\n 9:34 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ABD.PAIN\n Admitting Diagnosis: CHEST PAIN,HYPERTENSION\n Field of view: 47\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1) Slight increase in the amount of intraperitoneal air. No extravasation of\n enteric contrast from the bowel and no bowel wall thickening to suggest bowel\n injury or perforation. This air is likely due to the patient's peritoneal\n dialysis.\n\n 2) 1 cm focus of subcutaneous air just anterior to the abdominal wall at the\n level of the umbilicus probably refelcts a small fascial defect in the\n anterior abdominal wall.\n\n 3) Stranding around the head of the pancreas is unchanged but could indicate\n mild pancreatitis.\n\n 4) No evidence of bowel ischemia, inflammation, or mesenteric infarction.\n\n" }, { "category": "Radiology", "chartdate": "2133-09-06 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 798105, "text": " 8:00 PM\n CT ABDOMEN W/CONTRAST; CTA CHEST W&W/O C &RECONS Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: eval for AAA - non contrast\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with hypotension, abd pain, and on peritoneal dialysis\n REASON FOR THIS EXAMINATION:\n eval for AAA - non contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DCsc SUN 10:46 PM\n NO ANEURYSM OR DISSECTION\n GALL STONES\n NO CHOLECYSTITIS\n ATELECTAIS VS EARLY CONSOLIDATION IN THE LINGULA\n WET READ VERSION #1 DCsc SUN 9:58 PM\n NO ANEURYSM OR DISSECTION\n GALL STONES\n NO CHOLECYSTITIS\n ______________________________________________________________________________\n FINAL REPORT\n CT ANGIOGRAM OF AORTA\n\n INDICATION: Abdominal pain, hypotension, on peritoneal dialysis.\n\n TECHNIQUE: Noncontrast and post contrast images were obtained from the aortic\n arch to the aortic bifurcation.\n\n CONTRAST: 100 cc Optiray nonionic IV contrast were administered due to the\n rapid rate of bolus required for the CT angiogram protocol.\n\n There is no prior study for comparison.\n\n CT CHEST BEFORE AND AFTER IV CONTRAST: There is no axillary, hilar, or\n mediastinal adenopthy. There is coarse calcification of the coronary arteries\n and aortic arch and a stent at the origin of the left subclavian artery. The\n patient is post CABG: median sternotomy wires and vascular clips are\n identified within the mediastinum. There is no mediastinal hematoma. There\n is mural thrombus throughout the course of the aorta but there is no\n dissection or aneurysmal dilatation. There is linear and dependent\n atelectasis. Additionally, there is atelectasis vs early consolidation within\n the lingula. There is no effusion or pneumothorax. The esophagus is mildly\n dilated and there is a small axial hiatal hernia.\n\n CT ABDOMEN BEFORE AND AFTER IV CONTRAST: There is fatty infiltration of the\n liver. Gallstones are seen within the gallbladder but the gallbladder is\n nondistended. There is no intrahepatic biliary dilatation. The pancreas,\n spleen, and adrenal glands appear normal. The kidneys are atrophic and a\n calcificaiton is seen within the right kidney posteriorly. There is a\n moderate amount of ascites within the abdomen, consistent with the patient's\n peritoneal dialysis. There is no free air. The celiac axis, SMA, SMV, portal\n (Over)\n\n 8:00 PM\n CT ABDOMEN W/CONTRAST; CTA CHEST W&W/O C &RECONS Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: eval for AAA - non contrast\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vein, and splenic vein are patent. Most of the bowel is imaged and there is\n no evidence of bowel wall thickening or liminal dilatation.\n\n LIMITED CT VIEWS OF THE PELVIS AFTER IV CONTRAST: Images are only obtained\n through to the bifurcation of the iliacs. No masses are seen within the\n pelvis to this level. No suspicious osseous lesions are identified.\n\n IMPRESSION:\n 1) No aortic aneurysm or dissection.\n\n 2) No intraabdominal abscess or bowel obstruction.\n\n 3) Atelectasis vs early consolidation within the lingula.\n\n" }, { "category": "Radiology", "chartdate": "2133-09-08 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 798275, "text": " 4:36 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for retroperitoneal and thigh bleeding\n Admitting Diagnosis: CHEST PAIN,HYPERTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with CAD s/p PCI with prolonged antiplatelet therapy with\n falling hematocrit\n REASON FOR THIS EXAMINATION:\n assess for retroperitoneal and thigh bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreasing hematocrit with prolonged anti-platelet therapy,\n status post catheterization.\n\n TECHNIQUE: Helically-acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis, following the administration of oral\n contrast only.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Atelectasis is noted at both lung\n bases, left greater than right. Retained contrast enhancement is noted\n adjacent to the gallbladder fossa, possibly representing asymmetric perfusion.\n Vicarious excretion of contrast is noted filling the gallbladder, where there\n are two filling defects consistent with gallstones. The pancreas is poorly\n seen given the adjacent edema and fluid throughout the abdomen. The spleen,\n adrenal glands and loops of bowel are unremarkable. A peritoneal dialysis\n catheter is noted traversing the anterior abdomen. There is extensive free\n fluid, consistent with patient's known peritoneal dialysis. This tracks down\n into the pelvis. There are no abnormally dilated loops of bowel or focal\n collections. The kidneys are both atrophic, with multiple gallstones. There\n are extensive vascular calcifications. There is a trace amount of free\n intraperitoneal air, also probably related to peritoneal dialysis.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid colon and urinary\n bladder are unremarkable. There is a large amount of free pelvic fluid. No\n deep pelvic lymphadenopathy. There is an intramuscular lipoma seen adjacent\n to the right inferior pubic ramus. No abnormal collections are noted adjacent\n to the right groin or within the retroperitoneum.\n\n The osseous structures are diffusely osteopenic.\n\n IMPRESSION:\n 1) No evidence of local hematoma or retroperitoneal hemorrhage.\n 2) Extensive free fluid and air within the abdomen, consistent with patient's\n known peritoneal dialysis.\n 3) Gallstones, without definite evidence of cholecystitis.\n 4) Left lower lobe atelectasis, left greater than right.\n 5) Lipoma seen adjacent to the right inferior pubic ramus.\n (Over)\n\n 4:36 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for retroperitoneal and thigh bleeding\n Admitting Diagnosis: CHEST PAIN,HYPERTENSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Echo", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 69049, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Coronary artery disease.\nHeight: (in) 60\nWeight (lb): 220\nBSA (m2): 1.95 m2\nBP (mm Hg): 80/48\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 14:32\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nThere is no resting left ventricular outflow tract obstruction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anteroseptal - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Right ventricular\nsystolic function cannot be reliably assessed.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. Mild (1+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. The\npatient is bradycardic (HR<60bpm). Based on AHA endocarditis prophylaxis\nrecommendations, the echo findings indicate a low risk (prophylaxis not\nrecommended). Clinical decisions regarding the need for prophylaxis should be\nbased on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\ncavity size are normal. Resting regional wall motion abnormalities include\nseptal hypokinesis. Overall systolic function is good, though regional\nfunction cannot be fully assessed due to suboptimal technical quality Right\nventricular cavity size is normal. The aortic valve leaflets (3) are mildly\nthickened but not stenotic. No aortic regurgitation is seen. The mitral valve\nleaflets are structurally normal. Mild (1+) mitral regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the findings of the prior study (tape reviewed) of , the\nseptal hypokinesis appears to be new.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2133-09-06 00:00:00.000", "description": "Report", "row_id": 155456, "text": "Atrial fibrillation with a controlled ventricular response. Diffuse\nnon-specific ST-T wave abnormalities. Compared to the previous tracing\nof atrial fibrillation has appeared.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2133-09-13 00:00:00.000", "description": "Report", "row_id": 155452, "text": "Sinus rhythm. First degree A-V block. Non-specific lateral ST-T wave changes.\nLow QRS voltages in the limb leads. Compared to the previous tracing of \nthe rate has increased. Otherwise, no diagnostic changes are noted.\n\n" }, { "category": "ECG", "chartdate": "2133-09-08 00:00:00.000", "description": "Report", "row_id": 155453, "text": "Sinus rhythm. A-V conduction delay. Diffuse low voltage. Compared to the\nprevious tracing of there are Q-T interval prolongation, slowing of\nthe rate, absence of ventricular ectopy and some improvement in the T wave\nabnormalities. Otherwise, no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2133-09-07 00:00:00.000", "description": "Report", "row_id": 155454, "text": "Sinus rhythm and occasional ventricular ectopy. Diffuse low voltage.\nA-V conduction delay. Non-specific ST segment flattening. Compared to the\nprevious tracing of sinus rhythm and ventricular ectopy have appeared.\nOtherwise, no diagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2133-09-06 00:00:00.000", "description": "Report", "row_id": 155455, "text": "Atrial fibrillation with a controlled ventricular response. Diffuse\nnon-specific ST-T wave abnormalities. Compared to the previous tracing\nof no diagnostic interim change.\nTRACING #2\n\n" } ]

[ { "category": "Radiology", "chartdate": "2186-06-08 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 792611, "text": " 2:01 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for aorto-enteric fistula at site of prior AAA repair;\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man presenting with melena, h/o recurrent dvts on coumadin, CAD,\n hemachromatosis, diabetes\n REASON FOR THIS EXAMINATION:\n eval for aorto-enteric fistula at site of prior AAA repair; please also do\n venous phase to check for portal vein patency\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Melena, on Coumadin. ?Aortoenteric fistula at site of\n prior AAA repair.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis before and after the administration of\n 150 cc of Optiray contrast intravenously. Optiray was used per fast bolus CTA\n protocol.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST AND ABDOMINAL AORTIC CTA: There is\n minimal bibasilar atelectasis, left greater than right. There are no pleural\n effusions. There is a subtle nodularity to the liver contour and the liver\n appears small in size with a large caudate lobe, findings suggestive of\n cirrhosis. There is a trace amount of fluid surrounding the liver and spleen\n and the mesentery is edematous. The spleen, pancreas, gallbladder, adrenal\n glands, kidneys, ureters, and non- contrast-opacified bowel loops are\n unremarkable. There are several prominent retroperitoneal lymph nodes in the\n paraaortic and aortocaval regions just inferior to the renal vessels, none of\n which reach CT criteria for pathologic enlargement. There is no mesenteric\n lymphadenopathy. There is no free air. Omental fat is noted to be herniating\n through the midline into the subcutaneous fat in the upper abdomen.\n\n The abdominal aortic CTA demonstrates conventional anatomy without evidence of\n extravasation from the aortic into bowel loops. There is no abdominal aortic\n aneurysm, however, there is an approximately 2.5-cm calcified aneurysm of the\n left internal iliac artery. The superior mesenteric, splenic, and portal\n veins are patent. Venous collateralization from the splenic hilum to the\n umbilicus is noted. Note is made of an inferior accessory right renal artery.\n\n CT PELVIS WITHOUT AND WITH INTRAVENOUS CONTRAST: The distal ureters and\n urinary bladder are unremarkable. There are bilateral fat-containing inguinal\n hernias. There is a small amount of free fluid in the pelvic peritoneum.\n There is no lymphadenopathy.\n\n There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n\n (Over)\n\n 2:01 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for aorto-enteric fistula at site of prior AAA repair;\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1) Fine nodular contour of the liver with an enlarged caudate lobe plus a\n small amount of abdominal ascites is suggestive of cirrhosis. There is also\n evidence of portal hypertension with collateralization from the splenic hilum\n to the umbilical plexus.\n\n 2) No evidence of aortoenteric fistula.\n\n 3) Anterior wall omental fat herniations.\n\n 4) Left internal iliac artery aneurysm measuring 2.5 cm with calcified wall.\n\n" }, { "category": "Radiology", "chartdate": "2186-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792568, "text": " 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with hx of cardiomyopathy a/w GIB, s/p 3L NS and blood\n products.\n REASON FOR THIS EXAMINATION:\n eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiomyopathy. Status-post resuscitation from GI bleed. Question\n CHF.\n\n TECHNIQUE: Single portable AP view of the chest without comparisons\n demonstrates a borderline enlarged cardiac silhouette without evidence of\n overt failure. There is mild pulmonary vascular redistribution. No focal\n pulmonary opacities, pleural effusions, or pneumothorax. There is minimal\n linear atelectasis at the left costophrenic angle.\n\n IMPRESSION: Cardiomegaly and mild pulmonary vascular redistribution; no\n evidence of overt failure.\n\n" }, { "category": "ECG", "chartdate": "2186-06-09 00:00:00.000", "description": "Report", "row_id": 106703, "text": "Sinus rhythm, rate 70. Possible old inferior myocardial infarction.\nNon-specific QRS notching in leads V2-V3. Minor non-specific repolarization\nchanges. Compared to the previous tracing of probably no significant\nchange.\n\n" }, { "category": "ECG", "chartdate": "2186-06-07 00:00:00.000", "description": "Report", "row_id": 106704, "text": "Normal sinus rhythm. Left atrial abnormality. Compared to the previous\ntracing #1, no diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2186-06-07 00:00:00.000", "description": "Report", "row_id": 106705, "text": "Normal sinus rhythm. Low precordial lead voltage. Delayed R wave transition.\nLeft axis deviation. Small Q waves in leads V1-V3 suggest possible anterior\nmyocardial infarction. Compared to the previous tracing of the\nST segment elevations in the anterior leads are no longer present.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2186-06-08 00:00:00.000", "description": "Report", "row_id": 1293772, "text": "M/SICU NURSING PROGRESS NOTE.\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: alert and oriented x 3. Pupils 3mm and brisk. Speach is clear and is able to make needs known. Moving all extrem. well with good strength. Temperature max. 98.7 oral.\n\n Respiratory: Lung sounds are clear and eqaul throughout. RR 12-20 and non labored. O2 saturation 95-98% on ra. No cough noted.\n\n CV: Sinus rhythm with rare pvc's notred, rate 70's. Nbp in mid 80's to low 100's. Infusing ns at 250cc/hr. Transfusing 1st unit of 2 units prbc's. Will be infusing 2 units platelets at 0600 with a 3rd unit on standby.\n\n GI/GU: Abdomen soft with + bs. No bm this shift. Npo except meds which are on hold until after egd. Voiding clear yellow urine in urinal. No c/o abd. pain. Hernia in mid epigasrric region from aaa repair noted.\n\n Social: Wife and daughter into see pt upon arrival to micu, went home and will be back in today.\n\n Plan: Egd this am, transfuse blood products, monitor vital signs and hct.\n" }, { "category": "Nursing/other", "chartdate": "2186-06-08 00:00:00.000", "description": "Report", "row_id": 1293773, "text": "Nursing Progress Note 7a-7p M/SICU:\n\nNeuro: AAOx3, MAE, PERLA reactive at 3mm and equal. Foot drop noted r/t previous spinal surgergy.\n\nResp: Remains on RA with sats 96-99%. Lungs with occasional crackles in bases, clear in upper lobes. No SOB/dsypnea.\n\nCV: SR with HR 60-80's. BP 88-100's systol. +palp peripherial pulses x 4. Slight generalized edema noted. CT of abd. done this afternoon. 2 additional units of FFP given (4 units total) and 1 unit of PRBC's (3 units total). Afebrile. Magnesium sulfate 2gms given. SW x 2 #18g in place with KVO to R wrist.\n\nGI: + BS noted. No N/V noted. have clear liquid til GI prep started. Scheduled for Colonoscopy in AM. Needs Golytely tonight to start at 20:00. No Bm today.\n\nGU: Voids in urinal without difficulty.\n\nSocial: Family in to see patient. Wife here most of the day. Talked to MD's.\n\nPlan: Cont. to monitor VS's, LAB values, I&O, continue with current plan of care. GI prep tonight for Colonoscopy in AM.\n" }, { "category": "Nursing/other", "chartdate": "2186-06-10 00:00:00.000", "description": "Report", "row_id": 1293778, "text": "S/MICU Nursing Progress Note\n GI: no stool toady, abd slightly distended but soft, +flatus,denies any pain,nausea, started on clear liguids this morning and advanced as tolerated, Hct at 1700 stable at 34 (up from 32 this morning) no epigastric discomfort today.\n Cardiac: HR 60-70's NSr no VEA, BP stable at 110-120/60's no episodes of hypotension. KVO fliuds stopped as pt is taking po's without difficulty. good urine output no always measured as up using the bathroom.\n Respiratory; placed on RA this morning and tolerated well. BS clear.\n GU: voiding without difficulty.\n Neuro:pt calm, A&O x3 up to chair x 2 without difficult, steady on feet.\n Plan: awaiting a medical bed.\n" }, { "category": "Nursing/other", "chartdate": "2186-06-11 00:00:00.000", "description": "Report", "row_id": 1293779, "text": "SMICU nsg progress note\nS/O GI- Cont with slighty distended abdomen. No s/s bleeding. Denies nausea/gi distress. Hct stable at 34.7\nCardiac- Stable bp/hr. Denies cp. Cont with adequate uo\nResp- Sats stable on ra. No c/o sob\nNeuro- Alert oriented and cooperative.\nA/P-Stable. Cont to watch for bed on medical floor.\n" }, { "category": "Nursing/other", "chartdate": "2186-06-11 00:00:00.000", "description": "Report", "row_id": 1293780, "text": "S/MICU Nursing Progress Note\n GI: hct stable at 34, advanced diet to low cholestrol/diabetic diet tolerated well. up amb in the room without difficulty.\n Cardiac: HR 60-70's NSR telemetry was D/C after am rounds. BP stable at 110-120/70's Nadol given at 1pm.\n Resp. On RA BS clear, no difficulty, no c/o.\n Pt discharged home with prescriptions for Nadadol,sucrafate,protonix,dilatin,gluribide, instructed not to take coumadin,ASA,lipotor,atenol. Reveiw instruction about calling Dr and Dr. for follow up visits. Review instructions with daughter and wife. Discharged home at 2pm.\n" }, { "category": "Nursing/other", "chartdate": "2186-06-09 00:00:00.000", "description": "Report", "row_id": 1293774, "text": "MICU NPN 1900-0700\nNeuro: Pt is a&ox3, calm and cooperative. Slept on and off overnight.\n\nCV: HR 70's-80's, NSR, no ectopy noted. BP 90's-100's/40's-50's. Post-transfusion HCT 31.4 from 26. Am labs pending. Afebrile.\n\nResp: LS's CTA, RA sat 94-96%. RR 18-20, non-labored.\n\nGI: Abd soft/+bs's, non-tender. Drinking Golytely overnight in preparation for colonoscopy this am. Pt moving bowels frequently and report dark liquid stool this morning after drinking ~ of golytlely.\n\nGU: Pt voiding in toilet in without difficulty. Pt reports he is going in adequate amounts. Unable to quantify.\n\nSkin: No breakdown noted to backside. Pt OOB to commode without c/o dizziness, steady gait. PIV x2 #18, flushed and patent.\n\nPlan: To have colonoscopy today, follow-up am HCT.\n" }, { "category": "Nursing/other", "chartdate": "2186-06-09 00:00:00.000", "description": "Report", "row_id": 1293775, "text": "NURSING PROGRESS NOTE FOR M/SICU 7A-7P:\n\nNEURO: AAOX3, , . RECEIVED VERSED 7MG AND FENANTYL 200MCG IV DURING TODAY'S PROCEDURES. UP AD LIB PRIOR TO PROCEDURE\n\nCV: SR WITH NO ECTOPY. BP STABLE. AFEBRILE. + PALP. PERIPHERIAL PULSES X 4. NO EDEMA NOTED. NEEDS TO RECEIVE 1 UNIT PRBC'S THIS AFTERNOON. SW X 1 #18G TO LEFT AC PATENT AND FLUSHED.\n\nRESP: RA WITH UNLABORED AND REGULAR RESPIRATIONS. LUNGS CTA. SATS 93-98%.\n\nGI: + BS NOTED. NO N/V NOTED. CONTINUED TO HAVE FREQUENT BM'S THIS AM PRIOR TO COLONOSCOPY (GREENISH LIQUID). OFF FLOOR FROM 12:40 - 16:45 FOR COLONOSCOPY/ENDOSCOPY TODAY. EGD DONE WITH BANDING OF VARICES. ONLY ABLE TO DO COLONOSCOPY AS FAR AS ASCENDING COLON. NO ACTIVE BLEEDING NOTED.\n\nGU: VOIDS IN BEDSIDE COMMODE WITHOUT DIFFICULTY.\n\nPLAN: CONT. WITH PLAN OF CARE, MONITOR VS'S, LABS, I&O, ETC. CALLED OUT TO FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2186-06-09 00:00:00.000", "description": "Report", "row_id": 1293776, "text": "Additional note: Received back to Rm 410 from GI UNit post colonoscopy/ edg with banding of varices in stable condition. C/O CP in recovery x 1. EKG done with no changes. C/O Chest/epigastric pain x 1 at 1810. EKG done with no changes MD 2 mg IV given with min. effect. KCL 40 meq in 500cc needs to be started. New SW #20g. inserted in Left arm without difficulty. Family in room with patient. Spoken with ICU resident.\n" }, { "category": "Nursing/other", "chartdate": "2186-06-10 00:00:00.000", "description": "Report", "row_id": 1293777, "text": "S/MICU Nursing Progress Note 7pm-7am\nSee Carevue for Additional Objective Data\n#1:GIB\nD:A&Ox3,Denies c/o N/V/Abd pain\nAbd soft, non-tender, +BS, passing flatus, no BM overnoc. C/O epigastric pain, relieved somewhat with position change and Xylocaine slurry\nTaking sips of water with meds, tolerating this well\nAfebrile\nHemodynamically stable.\n4L NC with RR:/min SpO2:>96% BS:CTA\n\nA:Post transfusion hct:32.8,PT:16.2,PTT and INR:WNL\n Carafate started\n Nadolol started\n\nR:Stable overnoc without any s&sx of bleeding, continue with supportive care as previously documented, transfer to medical floor when bed available\n" } ]

[ { "category": "Nursing/other", "chartdate": "2168-07-11 00:00:00.000", "description": "Report", "row_id": 1366119, "text": "MICU 6 Nursing Admission Note (2300-0700)\n\nPlease see FHPA.\nPlease see carevue for all objective data.\n\nPt. is a 79 year old woman transferred from CC7 with hypotension and poor UOP. Pt.has multiple medical problems and was originally admitted to the hospital due to dyspnea, pleuritic chest pain and BLE edema. CXR showed CHF and left pleural effusion along with an enlarged heart. Diuresis was only moderately successful. ECHO showed EF of 40% with ?anterior wall motion abnormalities. Cardiac cath showed non ischemic cardiomyopathy.\nThoracentesis done due to dyspnea and persistent pleural effusions....?exudate vs. RA vs. malignancy. CT showed lesion in left kidney and an MRI was done (results pnd).\nPt. transferred to MIVU6 after N/V, diarrhea, low grade temp and hypotension (70's/syst) along with poor UOP. Received a liter of IVF on the floor without improvement.\nStat ECHO done to rule out tamponade.\n" }, { "category": "Nursing/other", "chartdate": "2168-07-13 00:00:00.000", "description": "Report", "row_id": 1366125, "text": "NPN 1900-0700:\n\nEVENTS: Pt called out to floor, had bed, but then lost it to an ED patient. Remains in ICU awaiting 3 bed.\n\nPt having short runs of HR 130's-140's during the evening in the setting of mild hypoxia (sats low 90's on RA). Placed back on 2L NC with sats improving to mid 90's and no further episdoes of tachycardia. Underlying rhythm remains afib/flutter 100-120 with no VEA. BP stable. Tolerating Lopressor 25mg TID. Remains on 2L NC with RR 24-36, SOB with exertion, but otherwise resting comfortably. UO remains somewhat low but overall improved; BUN/creat nearly normal now at 24/1.1.\n\nPLAN: Continue current management; MRI when able; to floor when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2168-07-13 00:00:00.000", "description": "Report", "row_id": 1366126, "text": "Shift Note\nCV: HR 90-105, a-fib/flutter...lopressor dose increased today. NIBP stable Heparin gtt...next ptt draw 1800 with goal ptt 50-70.\n\nResp: 2L NC, sats >95%. BBS clear with crackles in bases.\n\nNeuro: A/O x3, denies pain\n\nGI/GU: Abdomen soft, BS present. Tolerating cardiac/diabetic diet well. Fluid restriction with no free water. Pt instructed not to drink water, but may have juice instead. BM x1. Foley intact, UO marginal\n\nID: Afebrile\n\nEndo: Started on SSI d/t hyperglycemia related to initiation of steriods.\n\nSee transfer note\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2168-07-27 00:00:00.000", "description": "Report", "row_id": 1366127, "text": "CCU Nursing Progress Note 1900-0700\nS: \"Take these things off my arms\".\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: Received pt s/p resp arrest induced by 7 mg Morphine IV post procedure. Pt had undergone pleuradesis on prior shift. During code pt had received 0.4 mg IV Narcan w/ some effect. Upon initial assessment pt 1. Noncompliant to care requiring soft wrist restraints to maintain appropriate oxygenation. Narcan gtt was started and turned off at 0500. Pt 3 at that time. MAE. PEARL. Following simple commands. Pt denies any pain.\n\nCV: Chronic PAF. HR 126-140. No vea. HR decreased to 111-116 following Metoprolol dose. NIBP 131-149/80-90. MAPs>105. Heparin continues at 750 units/hr as bridge to at home Coumadin regimen. HCT 25.4. Slight decline. HO aware. Pt has h/o anemia. K+ 4.9 and Mg 1.5. Ekg obtained w/ peaked twaves. Pt received Kaexylate x1 and repleted w/ 2 gm CaGluc and 3 gm MGSO4.\n\nResp: Received pt on NRB. Decreased to FM 40% at 10 LPM. Pt tolerated wean w/o difficulty, RR 16-23. O2 sats 96-100%. Pt denies SOB. LS clr in apexes and diminished in bases. Pt has good cough and gag. S/P bilateral chest tubes. Received pt w/ JP drain clamped. Surgery ordered for drain to be unclamped overnoc. Emptied JP drain for 100cc drainage.\n\nGI/GU: NPO overnoc given compromised MS. w/ low salt diet. NA 127. Pt placed on free water restriction and 1500 ml fluid restriction. F/C placed. UOP marginal. Pt +600cc LOS. BUn/Cr 25/1.1.\n\nID: Tmax 96.0 axillary. WBC 6.4. Pt continues on Bactrim while on steroids.\n\nEndo: BS 300. Received 4 units coverage per RISS. On Prednisone for treatment of RA.\nSkin: Intact.\n\nSocial: Spoke to eldest dtr . Family is unclear of advanced directives. Suggested HCP designation while in hospital setting. Cont to follow. Pt lives at home w/ husband of 53 . There are three dtrs per pt.\n\nA/P: 79 yo female w/ significant pmhx and lengthy hospitalization. Course c/b hypotension, pleural/pericardial effusions s/p vats procedure w/ pericardial window, chest tubes and pleurodesis. S/P resp arrest secondary to morphine received for pain mgmt post procedure. Pt received Narcan IVB and started on gtt. Narcan gtt dc'd overnoc. MS improving. Cont to follow UOP. Follow electrolytes and replete as indicated. Cont to advance diet and activity as tolerated. Cont supportive care. Keep family updated in POC. Likely transfer to floor today. \u0014\n" }, { "category": "Nursing/other", "chartdate": "2168-07-11 00:00:00.000", "description": "Report", "row_id": 1366120, "text": "(cont'd) History includes: HTN, hypercholesterolemia, occipital migraines, RA, colonic adenomas, +smoker (stopped on admission), AFIB, osteoporosis, Raynaud;s and spinal stenosis.\nPt. lives at home with her husband.\n\nCNS: Pt. alert, oriented and cooperaive. MAE's. PEARL. Very pleasant. Trazadone 25mg given for sleep with good effect.\n\nCVS: Heart rate 80-90, AFib with occ. PVC's. Hypotesive with SBP 90/, drifts down to 78/ while asleep. MAP 58-60. Minimal UOP throughout the night. Neither blood pressure or UOP has responded satisfactorily to several fluid boluses (total one liter on CC7 and one liter overnight in MICU).\n\nRESP: Lungs with rales 1/2 up bilaterally on admission, unchanged despite further IVF. Sats of 96% on 2lnc. RR in the mid 20's. Pt. denies any SOB. CXR repeated at 0400 with results pending.\n\nID: Afebrile, on vanco and levofloxacin. One set of BC sent, needs a second. Needs stool for CDiff.\n\nGI: Abdomen with active bowel sounds. Denies N/V. Tolerating small amounts po food and fluids.\n\n\nSKIN: Pt is quite cachectic, although no skin breakdown noted.\n\nSOCIAL: Pt. spoke to family via telephone\n" }, { "category": "Nursing/other", "chartdate": "2168-07-11 00:00:00.000", "description": "Report", "row_id": 1366121, "text": "Shift Note 0700-1900\n79 y/o Female with RA, CHF, Afib admitted to floor with c/o dyspnea, CP and BLE edema; ?CHF and diuresed. CXR showed new left pleural effusion---thoracentesis performed (no growth on cx, considering VATS once stable. New renal mass on CT scan and MRI performed with poor quality of study. ?Repeat MRI tomorrow. EF 40% ?wall motion abnormalities and cardiac cath performed showing non-ischemic cardiomyopathy. Developed hypotension with decreased UO on floor and transferred to MICU. Repeat ECHO this am.\n\nCV: HR 90's a-fib with NIBP intially 84-93/40-50's with MAP 56-65...given total 2L IVF's last night and received additional 1.5L NS today. BP finally stable low 100's/50's. Pt then started to have frequent bursts of HR upto 150's...quickly resolved w/o intervention and patient asymptomatic. Resident paged and notified...pt started on low dose PO lopressor (beta-blockers held in setting of hypotension which was most likely d/t over-diuresis). Please notify resident if lopressor dose needs to be held. EKG obtained and rhythm appearing to be a-flutter. Continue to assess HR, if symptomatic may need IV lopressor. Continue to titrate lopressor dose as BP tolerates. Started on Heparin gtt for a-fib at 750units/hr...goal Ptt 50-60. Last ptt 66.8; heparin gtt decreased to 650units/hr and next ptt to be sent at midnight.\n\nResp: 2L NC with sats >96%, BBS clear with faint crackles in bases, L>R. RR 20's, pt denies SOB or trouble breathing.\n\nNeuro: Alert/oriented x3, very pleasant and cooperative. Denies pain, c/o discomfort when sitting on coccyx (stage 1 pressure sore noted and barrier cream applied) pt shifting weight in bed.\n\nGI/GU: Abdomen soft, BS present. Pt on low Na-cardiac prudent diet; tolerating well. Foley intact; low UO persists 5-38cc/hr. Since patient only weighs 52kg, appropriate UO ~25cc/hr per resident. ARF likely d/t prerenal causes (hypotension/dehydration). No BM this shift; needs C-Diff specimen sent.\n\nSkin: Coccyx reddened; barrier cream applied\n\nID: Afebrile...abx stopped d/t low likelihood of bacteremia. F/U BC and Urine cx.\n\nSocial: Husband/children present at bedside today. Pt full code and states that daughter is HCP. most likely be c/o floor tomorrow am.\n\n" }, { "category": "Nursing/other", "chartdate": "2168-07-12 00:00:00.000", "description": "Report", "row_id": 1366122, "text": "NPN 1900-0700:\n\nRESP: Cont's with faint crackles at bases; sats high 90's on 2l NC with RR 26-34, non-labored.\nC-V: HR 100-120, afib/flutter, with rare burst to 150-170 during the evening, none since. PO Lopressor increased to QID. BP stable 90's-100's with MAP >60. Hep gtt cont's; rate increased for subtherapeutic PTT.\nGU: UO has picked up quite a bit since MN and he is now running negative (? starting to auto-diurese). BUN/creat stable at 27/1.3.\nHEME: 5-pt hct drop to 26.8; ? dilutional. No obvious source of bleeding.\n\nA: much improved\n\nP: Increase Lopressor as tolerated; re-check PTT at 0800 and adjust heparin prn; follow resp status closely; OOB to chair; ? c/o to floor today.\n" }, { "category": "Nursing/other", "chartdate": "2168-07-12 00:00:00.000", "description": "Report", "row_id": 1366123, "text": "Shift Note 0700-1900\nCV: HR 90-110, a-fib/flutter with no ectopy. Continues on heparin gtt with goal ptt 50-60. Last ptt subtherapeutic at 36.3 and gtt increased by 200units/hr to 950units/hr with bolus held per resident. Next ptt midnight. NIBP 100-120/50-60's; stable and lopressor dose increased. Am hct 26.8 (31.4)...fluid resuscitated yesterday. Repeat Hct 28.5.\n\nResp: BBS clear with crackles in LLL. RR 20's, sats >97% on RA. Pt denies SOB.\n\nNeuro: A/O x3, very pleasant. Denies pain.\n\nGI/GU: Abdomen soft, BS present. Tolerating cardiac diet well. Small dark bm, heme (-)...sent for C-diff. Foley intact; UO dropped this afternoon and 250cc NS bolus given with slight response. Pt taking PO fluids well with 2000ml fluid restriction. Urine lytes sent. Creat stable 1.3\n\nPlan: MRI renal/kidney. Started on predinsone.\n\nSocial: Full code; family at bedside this afternoon. Being evaluated by thoracic surgery for pleural /pericardial bx, ?VATS\n" }, { "category": "Nursing/other", "chartdate": "2168-07-12 00:00:00.000", "description": "Report", "row_id": 1366124, "text": "ADDENDUM:\nPt transferred to 3 in stable condition. Currently awaiting MRI and may have further w/u scheduled as well.\n" }, { "category": "Echo", "chartdate": "2168-06-30 00:00:00.000", "description": "Report", "row_id": 96822, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Shortness of breath.\nHeight: (in) 66\nWeight (lb): 114\nBSA (m2): 1.58 m2\nBP (mm Hg): 132/84\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 12:06\nTest: TTE (Congenital, complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Small secundum ASD.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.\nModerate-severe regional left ventricular systolic dysfunction. No resting\nLVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - akinetic; basal anteroseptal - hypo; mid anteroseptal -\nakinetic; anterior apex - akinetic; septal apex- akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Borderline\nnormal RV systolic function.\n\nAORTA: Mildly dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. No MS. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated. A\nsmall secundum atrial septal defect is present. Left ventricular wall\nthicknesses are normal. The left ventricular cavity size is normal. There is\nsevere left ventricular systolic dysfunction. Resting regional wall motion\nabnormalities include hypokinesis of the anterior septum and anterior wall\nalong with akinesis to dyskinesis of the mid to distal anterior septum and\nanterior wall. Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated. The ascending aorta is mildly dilated. The\naortic valve leaflets (3) are mildly thickened. There is no aortic valve\nstenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. Moderate to severe (3+) mitral regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension. There is a moderate\nsized pericardial effusion which is circumferential, but layers mainly\nposteriorly. There are no echocardiographic signs of tamponade.\n\nCompared with the report of the prior study (images unavailable for review) of\n, there is a moderate size pericardial effusion, the left ventricular\nejection fraction is significantly further reduced, the mitral regurgitation\nhas worsened and an ASD is noted.\n\n\n" }, { "category": "Echo", "chartdate": "2168-07-18 00:00:00.000", "description": "Report", "row_id": 96793, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 65\nWeight (lb): 114\nBSA (m2): 1.56 m2\nBP (mm Hg): 122/80\nHR (bpm): 96\nStatus: Inpatient\nDate/Time: at 09:57\nTest: TTE (Congenital, complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Left-to-right shunt\nacross the interatrial septum at rest. Small secundum ASD. Dilated IVC (>2.5\ncm).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate-severe\nglobal left ventricular hypokinesis. [Intrinsic LV systolic function likely\ndepressed given the severity of valvular regurgitation.] No LV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size. RV function depressed. Abnormal\nseptal motion/position.\n\nAORTA: Moderately dilated aortic root. Moderately dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: The pericardium may be thickened. No significant respiratory\nvariation in mitral/tricuspid valve flows. No evidence of constriction.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a\nmoderate risk (prophylaxis recommended). Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data. Left\npleural effusion.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. A\nleft-to-right shunt across the interatrial septum is seen at rest c/w a small\nsecundum atrial septal defect. The inferior vena cava is dilated (>2.5 cm).\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nThere is moderate to severe global left ventricular hypokinesis with septal\ndysnchrony. [Intrinsic left ventricular systolic function is likely more\ndepressed given the severity of valvular regurgitation.] No intraventricular\nthrombus identified. Right ventricular chamber size is normal. Right\nventricular systolic function appears depressed. The aortic root is moderately\ndilated. The ascending aorta is moderately dilated. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened.\nModerate to severe (3+) mitral regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. The pericardium may be thickened.\nThere is no evidence of pericardial constriction.\n\nCompared with the prior study (images reviewed) of , the previously\nnoted echolucent pericardial effusion is now echo dense c/w organized\neffusion/blood/thickened pericardium. Right ventricular free wall hypokinesis\nwas present on the prior study. The severity of mitral and tricuspid\nregurgitation are similar.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "Echo", "chartdate": "2168-07-11 00:00:00.000", "description": "Report", "row_id": 96794, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 60\nWeight (lb): 112\nBSA (m2): 1.46 m2\nBP (mm Hg): 91/47\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 00:08\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Severe global LV\nhypokinesis. Severely depressed LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate to severe\n(3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Physiologic (normal) PR.\n\nPERICARDIUM: Small to moderate pericardial effusion.\n\nConclusions:\n1.The left atrium is mildly dilated.\n2. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is severely\ndepressed. The septum is dyskinetic with anterior wall akinesis\n3. Right ventricular chamber size and free wall motion are hard to assess but\nis probably normal.\n4. There are three aortic valve leaflets. The aortic valve leaflets are mildly\nthickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation\nis seen.\n5. The mitral valve leaflets are moderately thickened. Moderate to severe (3+)\nmitral regurgitation is seen.\n6. There is a small to moderate sized pericardial effusion. There is no RV or\nRA collapse to suggest tamponade; There is not respiratory variation in mitral\ninflow.\n\nCompared to the echo on : The effusion maybe smaller. The overall LV\nfunction may be worse with anterior akinesis. The MR is probably .\n\n\n" }, { "category": "Echo", "chartdate": "2168-07-06 00:00:00.000", "description": "Report", "row_id": 96795, "text": "PATIENT/TEST INFORMATION:\nIndication: Focused stufy to f/u known pericardial effusion\nHeight: (in) 66\nWeight (lb): 114\nBSA (m2): 1.58 m2\nBP (mm Hg): 100/70\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 12:33\nTest: TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nA large left pleural effusion is present.\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Moderately depressed LVEF.\n\nRIGHT VENTRICLE: RV function depressed.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. Effusion\necho dense, c/w blood, inflammation or other cellular elements. No\nechocardiographic signs of tamponade.\n\nConclusions:\nOverall left ventricular systolic function is moderately depressed. Right\nventricular systolic function appears depressed. There is a moderate sized\npericardial effusion. The effusion appears circumferential, however, there is\nminimal fluid anterior to the RV. The effusion is echo dense, consistent with\nblood, inflammation or other cellular elements. There are no echocardiographic\nsigns of tamponade.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is similar. There is still no evidence of tamponade.\n\n\n" }, { "category": "ECG", "chartdate": "2168-07-11 00:00:00.000", "description": "Report", "row_id": 265007, "text": "Atrial fibrillation\nLeft bundle branch blockwith left axis deviation\nSince previous tracing of same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2168-07-11 00:00:00.000", "description": "Report", "row_id": 265008, "text": "Atrial fibrillation\nLeft bundle branch block with left axis deviation\nNo previous tracing available for comparison\n\n" }, { "category": "ECG", "chartdate": "2168-06-29 00:00:00.000", "description": "Report", "row_id": 265009, "text": "Atrial flutter/ atrial fibrillation with a moderate ventricular response.\nOccasional ventricular premature beat. Left axis deviation. Left bundle-branch\nblock. Compared to the previous tracing of atrial fibrillation is new.\n\n" }, { "category": "ECG", "chartdate": "2168-07-26 00:00:00.000", "description": "Report", "row_id": 265006, "text": "Atrial fibrillation with a rapid ventricular response. Left bundle-branch\nblock. Compared to the previous tracing of the ventricular response has\nincreased. Otherwise, no diagnostic interim change.\n\n" }, { "category": "Radiology", "chartdate": "2168-07-06 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 914193, "text": " 6:16 PM\n CT ABD W&W/O C; CT CHEST W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: CT torso to rule out occult malignancy, CrCl 35 mL/min.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 29 Contrast: OPTIRAY Amt: 130CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman, long-standing smoker, with pericardial effusion, weight\n loss. ? Occult malignancy.\n REASON FOR THIS EXAMINATION:\n CT torso to rule out occult malignancy, CrCl 35 mL/min.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old female, longstanding smoker, with pericardial\n effusion, weight loss. Evaluate for occult malignancy.\n\n COMPARISON: CT abdomen and pelvis dated .\n\n TECHNIQUE: Non-contrast imaging of the abdomen was obtained. Following the\n administration of 120 cc of intravenous Optiray, MDCT imaging of the chest,\n abdomen, and pelvis was performed.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: There is diffuse atherosclerosis in the\n aorta, and proximal branches. Mild coronary artery calcifications are seen.\n The heart is enlarged, with a large intermediate density pericardial effusion.\n There are moderate/large bilateral pleural effusions, with compressive\n atelectasis. There is no mediastinal, axillary, or hilar lymphadenopathy. The\n lungs are clear.\n\n CT ABDOMEN WITH ORAL, WITHOUT AND WITH INTRAVENOUS CONTRAST: The liver\n enhances normally without focal nodules or masses. Gallbladder, pancreas,\n spleen, bilateral adrenal glands, and abdominal loops of large and small bowel\n are unremarkable. Multiple low-density lesions are seen bilaterally, which\n are stable in size, and likely represent simple cysts. Some of these are too\n small to adequately characterize. In the upper pole of the left kidney, there\n is an 18 x 16 mm lesion which does not measure fluid density, and appears\n slightly larger than on prior exam requiring followup ultrasound. There is no\n mesenteric or retroperitoneal lymphadenopathy. There is no free air and no\n free fluid. Again noted is dense atherosclerosis and tortuosity of the\n abdominal aorta and iliac arteries.\n\n CT PELVIS WITH ORAL, WITHOUT AND WITH INTRAVENOUS CONTRAST: The bladder is\n collapsed. Sigmoid and rectum are normal. There is no inguinal or pelvic\n lymphadenopathy. There is no free air and no free fluid.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous\n abnormalities. Bones are demineralized.\n\n IMPRESSION:\n 1. Moderate pericardial effusion.\n 2. Moderate bilateral pleural effusions.\n (Over)\n\n 6:16 PM\n CT ABD W&W/O C; CT CHEST W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: CT torso to rule out occult malignancy, CrCl 35 mL/min.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 29 Contrast: OPTIRAY Amt: 130CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Cardiomegaly.\n 4. Hypodense lesion in the left kidney upper pole is larger and does not\n measure simple fluid density. Followup ultrasound is recommended for further\n evaluation.\n 5. Multiple bilateral simple renal cysts.\n\n\n\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2177-04-03 00:00:00.000", "description": "Report", "row_id": 1336043, "text": "SR C PAC. MAP STABLE ABOVE 60. K,MG REPLETED. HEPARIN 750 ,PTT 67.7.BOTH GROIN SITES HAVE SM HARD HEMATOMAS.DISTAL PULSES PRESENT.CI 2.5,SVR 896.C DOPA AT 2MIC/KG,W 23 .\n\nSAT 95 RM AIR.BS CL\n\nE/D WELL . 2U REG INSULIN FOR BS 212 .\n\nLASIX DRIP WEANED TO 2.5 MIC.HUO 100 TO 400.,NEG 5 L\n\nALERT,ORIENTED ,NO CO PAIN .OOB TO CHAIR TOL WELL.\n\nRESPONDING WELL TO DIUERETICS .\n\nRECHECK BLOOD WORK 4PM\nDC LASIX,DOPAMINE TONITE\n" }, { "category": "Nursing/other", "chartdate": "2177-04-04 00:00:00.000", "description": "Report", "row_id": 1336044, "text": "CCU progress note 7p-7a\nNEURO: A+Ox3. MAE. no c/o. slept well overnite.\n\nCV: SR 80-90s occ PACs. SBP 80-100s overnite. PA intact in RIJ. LASIX gtt off at 7pm, DOPA off at 8pm. BP stable. adequate u/o.\n\nRESP: LS clear. on room air. sats >95%.\n\nGI/GU: foley patent. good u/o. abd soft. +BS. +flatus. unable to have a BM. given MOM upon pt request. taking cardiac diet well. on FS QID w/ SSRI.\n\nPLAN: con't to monitor cardiac calcs. keep pt comfortable. ?OOB to chair today ?PA line to be removed.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-04 00:00:00.000", "description": "Report", "row_id": 1336045, "text": "CCU Nursing Progress Note 7a-7p:\n\nTransfer to when bed available. Please see admit data on written transfer note.\n\nCurrent review of systems:\n\nNeuro: Alert and oriented x 3. Pt pleasant and cooperative with all nursing care. Moving all extremities spontaneously.\n\nCV: NSR HR 70-90's no ectopy noted. Pt denies CP. SBP 90-110's. Maintaining presssure and u/o off dopa. Pt rec'd first dose of enalapril 2.5mg po at 2pm. Groins intact. Palpable pulses.\nConts on hep gtt at 750u/hr (off 12-3:30p for line d/c) check PTT at 9:30pm. No signs of bleeding noted. PA and art line d/c'd. Pt on lasix 40mg po bid. K and mg repleted.\n***Pt to be discharged home on a holter monitor...pt rec'd monitor and packet today in CCU, please review with pt and family memeber prior to d/c to home.\n\nPULM: LS CTA. RA. Denies SOB. Pt able to tolerate lying flat.\nEncouraged to c&db while in bed.\n\nGI: Abd soft NT +BS. Pt rec'd MOM and overnight for c/o constipation x 2 days. Pt currently having liquid ob neg brown stool x 4 this shift. Pt tolerating reg diet denies n/v.\n\nGU: Foley cath patent draining cyu 50-75cc/hr. -890 since mn (goal 1l) -6866 LOS.\nConts on lasix 40mg po bid.\n\nID: afebrile\n\nSKIN: intact\n\nENDO: FS QID. FS 187 at 12pm pt rec'd 2uR insulin per ss. Pt with NIDDM diet controlled prior to admission.\n\nLINES: 2 PIV in L arm.\n\nDISPO: full code\n\nSOCIAL: Wife and four children.\n\nP: Monitor VS on current meds. Check PTT at 9:30pm. Follow u/o goal fluid status 1 liter negative. FS QID. Monitor resp status.\nHolter Monitoring teaching prior to d/c to home. Provide support.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-02 00:00:00.000", "description": "Report", "row_id": 1336041, "text": "CCU admit note\npt accepted in transfer to CCU.\n\nHPI: pt admitted w/ dyspnea, found to be in rapid Aflutter. TEE done showed possible ablation in NSR. decreasing u/o -CR elevated 2.7.\n\nPMHX: CHF - cath EF 12-15%, HTN, NIDDM, prostate CA s/p prostatectomy, multiple myeloma - in remission, s/p hernia repair, Bilat total knee replacement, carpal tunnel surgery, prolapsed rectum.\n\nNKDA\nFULL CODE\n\nTransfered to CCU for PA line and further monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2177-04-03 00:00:00.000", "description": "Report", "row_id": 1336042, "text": "CCU progress note 7p-7a\nNEURO: A+Ox3. MAE. no c/o of pain or discomfort.\n\nID: Tmax 99.3 po. no abx\n\nCV: SR 80-90s occ PAC noted. SBP stable MAPS >60. R radial ALINE patent. RIJ PAline patent. Both lines placed last evening. Initial PA 47/27 CVP 11 PCWP 32 CO 4.4 CI 2.21 SVR 1236, PAsat 54%. Started on DOPAMINE @ 2mcg/k/min and LASIX @ 10mg/hr. AM cardiac outputs: PA 45/20 CVP 11, PCWP 23. CO 6.2 CI 3.12 SVR 1419 PAsat 64%. HEPARIN gtt @ 600u/hr. am PTT pnd.\n\nRESP: LS clear, NO SOB or SOBOE this morning. Pt stating his breathing feels great. Productive cough, expectorating sputum. encouraged to do DB+C. unable to obtain accurate sats, going by SAO2.\n\nGI/GU: foley patent, clear yellow urine, large amts >400cc/hr all nite. Lasix gtt @ 10mg/hr, Dopa @ 2mcg/k/min. abd soft, +BS. +flatus, no stool overnite. taking po well. FS QID.\n\n\nPLAN: con't to monitor cardiac calcs. monitor resp status. monitor diuresis progress. keep pt comfortable and updated on status.\n" }, { "category": "Echo", "chartdate": "2177-03-31 00:00:00.000", "description": "Report", "row_id": 96867, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 71\nWeight (lb): 164\nBSA (m2): 1.94 m2\nBP (mm Hg): 108/82\nHR (bpm): 124\nStatus: Inpatient\nDate/Time: at 16:19\nTest: Portable TEE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is dilated. No spontaneous echo contrast is seen\nin the body of the left atrium or left atrial appendage. Left atrial appendage\nemptying velocity is reduced (<20 cm/s). A probable thrombus is seen in the\nleft atrial appendage.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is dilated. No atrial septal\ndefect is seen by 2D or color Doppler.\n\nLEFT VENTRICLE: There is severe global left ventricular hypokinesis.\n\nRIGHT VENTRICLE: Right ventricular systolic function appears depressed.\n\nAORTA: The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. There is a\nsmall vegetation on the aortic valve.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild to moderate\n[+] tricuspid regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications.\n\nConclusions:\nThe left atrium is dilated. No spontaneous echo contrast is seen in the body\nof the left atrium or left atrial appendage. Left atrial appendage emptying\nvelocity is markedly reduced (<10 cm/s). Two mobile, echogenic masses are seen\nin the left atrial appendage on multiple views consistent with probable\nthrombus. The right atrium is dilated. No atrial septal defect is seen by 2D\nor color Doppler. There is severe global left ventricular hypokinesis. Right\nventricular systolic function appears depressed. The ascending, transverse and\ndescending thoracic aorta are normal in diameter and free of atherosclerotic\nplaque. The aortic valve leaflets (3) are mildly thickened. There is a small\nechogenic mass on the ventricular surface of the aortic valve. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nIMPRESSION: Probable left atrial appendage thrombus. Severe global hypokinesis\nof the left ventricle. Small mass on the aortic valve, most propably Lambl's\nexcrescences (differential diagnosis includes infective endocarditis, non\ninfective endocarditis, and papillary fibroelastoma).\n\n\n" }, { "category": "ECG", "chartdate": "2177-04-05 00:00:00.000", "description": "Report", "row_id": 263747, "text": "Sinus rhythm. Compared to tracing #1 no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2177-04-04 00:00:00.000", "description": "Report", "row_id": 263748, "text": "Sinus rhythm. Right bundle-branch block. Low limb lead voltage. Compared to the\nprevious tracing of no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2177-04-03 00:00:00.000", "description": "Report", "row_id": 263749, "text": "Sinus rhythm\n- frequent multifocal PVCs or aberrant ventricular conduction\nRight bundle branch block\nInferior/lateral ST-T changes may be due to myocardial ischemia\nSince previous tracing, rhythm change, ectopy\n\n" }, { "category": "ECG", "chartdate": "2177-03-31 00:00:00.000", "description": "Report", "row_id": 263750, "text": "Atrial flutter with rapid ventricular response\nRight bundle branch block\n Lateral ST-T changes are nonspecific\nRepolarization changes may be partly due to rhythm\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2177-03-31 00:00:00.000", "description": "Report", "row_id": 263751, "text": "Probable atrial flutter with rapid ventricular response\nRight bundle branch block\n Inferior/lateral ST-T changes are nonspecific\nRepolarization changes may be partly due to rate\nSince previous tracing, Normal sinus rhythm\n\n" }, { "category": "ECG", "chartdate": "2177-03-31 00:00:00.000", "description": "Report", "row_id": 263752, "text": "Possible atrial flutter with rapid ventricular response\nIndeterminate frontal QRS axis\nRight bundle branch block\n Inferior/lateral ST-T changes are nonspecific\nRepolarization changes may be partly due to rhythm\nSince previous tracing, rhythm changes\n\n" }, { "category": "ECG", "chartdate": "2177-03-31 00:00:00.000", "description": "Report", "row_id": 263753, "text": "Atrial fibrillation with a rapid ventricular response. Right bundle-branch\nblock. T wave inversions in leads V2-V6 are likely related to the rapid rate\nand/or lateral ischemia. Loss of R waves in leads VI-V3 suggestive of old\nanteroseptal myocardial infarction. Compared to the previous tracing of \natrial fibrillation with a rapid ventricular response is new. T wave inversions\nin the lateral leads are slightly prominent. Clinical correlation is suggested.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2192-03-01 00:00:00.000", "description": "Report", "row_id": 1347013, "text": "nursing admission note:\nplease see fhp for full pmh and hx of present illness.\n\npt arrived from approx 1630.\n\nneuro- alert and oriented x3 very pleasant. hx paraglegia to lower extremities. states wheelchair bound. perla. follows commands slight weakness noted on left hand grasp in comparison to right.\n\nresp- arrived on nasal cannula 4l with sats >93%. rr 16-28. very weak non-productive cough but sounds congested. lung sounds coarse with ? crackles at bases.\n\ncv- hr sr 80-100. no ectopy noted. sbp since arrival to micu 130-150's. She was hypotensive in ed and received total of 2 liters ns iv. + lower extremity edema bilaterally. pulses dopplerable.\n\ngi- abd soft nt nd positive bs, liquid stool on arrival, pt states frequently occurs. fecal incontinence bag applied. stool guiac negative. pt denies nausea at present and is currently have tea and toast.\n\ngu- foley patent for amber urine. per ed report +uti.\n\naccess- 2 #18 piv in r arm.\n\nid- temp 100.4 po. needs blood cx's one attempt unsuccessful. already received levoquin in ed.\n\nsocial- lives with daughter. has hha and vna services.\n\ncode status- dnr/dni\n\ndispo- admitted to micu with lll pneumonia and hypotensive in ed. continue to monitor bp, encourage pulmonary tolieting.\n\n" }, { "category": "Nursing/other", "chartdate": "2192-03-02 00:00:00.000", "description": "Report", "row_id": 1347014, "text": "Neuro: Pt. is a very pleasant A/A/O. Pt. is a paraplegic to lower ext's since . Pt. has denied any pain or discomfort at this time. Pt's temp has ranged from 98.9-99.8. Pt. did have one episode of drowsiness associated with hypotension. This was eased with fluid bolus and increase of B/P. Blood cultures x2 have been sent.\n\nC.V: Pt. has been NSR-ST 70-105, with no noted ectopy noted during this shift. +2 pitting edema noted to her lower ext's and pulses are doppled. Bilat hose applied during episode of hypotension. See carevue for V/S. Pt. is a DNR/DNI and it was determined that the pt. would not be placed on pressors. Pt. responded nicely to fluid bolus.\n\nResp: Pt. Lungs sounds are much unchanged from previous shift. Coarse sounds noted with crackles bibasilar. Exp. wheeze noted at times with neub Tx. started. Pt. has been 92-99%. Sputum to be collected, with pt. understanfing the need for the collection and container at bedside. Pt. has had a non productive cough during this shift.\n\nG.I: Abd is benign in assessment, with bowel sounds easily audible in all quadrants. Pt. is drinking adeqate amt's of fluids.\n\nG.U: Foley catheter in place while draining small but ample amt's of clear amber urine. Urine culture has been sent.\n\nI.V: Two 18 gauge heplocks intact and functioning well. I.V. of D5N/S infusing at 100cc/hr.\n\nSkin: No noted breakdown at this time.\n" }, { "category": "ECG", "chartdate": "2192-03-01 00:00:00.000", "description": "Report", "row_id": 277705, "text": "Sinus rhythm. Non-specific ST-T wave flattening in leads I, III, aVL and aVF.\nThe ST-T wave flattening is increased as compared to the previous tracing\nof but without No diagnostic interval changes.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2192-03-01 00:00:00.000", "description": "Report", "row_id": 277706, "text": "Sinus rhythm and occasional atrial ectopy. Left atrial abnormality.\nNon-specific ST-T wave flattening in leads I and aVL. Compared to the previous\ntracing of the rate has increased and there is occasional atrial\nectopy. Otherwise, no diagnostic change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2133-08-12 00:00:00.000", "description": "Report", "row_id": 1596410, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT REMAINS CRITICAL. REMAINS ON LEVO AND VASOPRESSIN. PRESSOR REQUIREMENTS INCREASED TO KEEP MAP>60. MAP MOSTLY 50'S. REMAINS PARALYZED AND SEDATED ON CISAT AND FENT. HR 80'S, NSR. NO ECTOPY. 2 U PRBC'S GIVEN AND HCT STABLE AT 30. 2 U FFP AND FACTOR 7 GIVEN AND COAGS IMPROVED. PLTS ALSO GIVEN. PT WITH LARGE AMT BLEEDING FROM NOSE AND MOUTH. NO RECTAL BLEEDING NOTED. ABD REMAINS FIRM AND DISTENDED. NO BS. CON'T ON PROTONIX AND OCTREOTIDE GTTS. ABGS REMAIN POOR. PAO2 WORSENING. PEEP INCREASED. WILL FOLLOW. O2 SAT 91% ON 80% FIO2. REMAINS ACIDOTIC. 2 AMPS BICARB GIVEN AND BICARB ADDED TO CVVH REPLACEMENT FLUID. PH IMPROVED TO 7.26. REMAINS ON CVVH. UNABLE TO REMOVE FLUID D/T BP ISSUES. REMAINS ANURIC.\nA/P-PT REMAINS CRITICALLY ILL. WILL CON'T CURRENT PLAN. FOLLOW LABS CLOSELY. CVVH. SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-12 00:00:00.000", "description": "Report", "row_id": 1596411, "text": "Pt remains intubated and mechanically ventilated. ABG's cont to improve slightly. VT increased to 600 and FI02 at 80%. Peep increased to 12cm. with an improvement in Pa02. PIP's 38-40. VE 17L-20L/min. BS: decreased, ess clear. Sx for small amts fo thick rusty colored secretions. 02 sats in 90's. PLan is to cont on mechanical ventilation and adjust vent settings accordingly. Current settings of A/C 34/ VT 600/80%/peep12cm.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-12 00:00:00.000", "description": "Report", "row_id": 1596412, "text": "NEURO; REMAINS ON PARALYTIC AND FENTANYL GTT, NO TWITCHES, PERL, NO GAG REFLEX,\n\nCARDIOVASCULAR; HR 80'S SR, BP VERY LABILE, FREQUENT TITRATION OF LEVOPHED AND VASOPRESSIN TO KEEP MAP 60 OR >, REPLETION OF PLATELETS, ONE UNIT FFP AND ONE PRBC GIVEN, ION CA LOW ALL SHIFT DESPITE CA GLUCONATE, AND CALCIUM CHLORIDE REPLETIONS, C.O. 9.0, SVR 317,\n\nRESPIR; PRESENTLY ON 12 OF PEEP AND FIO2 AT 80%, FI02 HAD BEEN AS HIGH AS 100%, P02 GRADUALLY IMPROVED DURING SHIFT, PH SLOWILY IMPROVING,\n\nRENAL: REMAINS ANURIC, ON , NOT ABLE TO ACHIEVE GOAL OF 20CC NEG, PFR SLOWLY INCREASED TO 70 AND PT TOLERATED WELL, ACCESS LINE CLOTTED AND NEW SET UP USED BUT NOT SUCCESSFUL, BOTH PORTS FLUSH WELL BUT CANNOT DRAW FROM BROWN PORT, TX HO INFORMED, WILL EVALUATE\n\nENDOCRINE; BS VERY LABILE, GIVEN 50D5W FOR GLUCOSE AS LOW AS 35, PRESENTLY ON D10 GTT\n\nPLAN; STABILIZE PT'S VSS, ATTEMPTS IF PT TOLERATES WITH BP, MONITOR GLUCOSE CLOSELY, SUPPORT OF FAMILY MEMBERS\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-08-13 00:00:00.000", "description": "Report", "row_id": 1596413, "text": "CONDITION UPDATED\nS/P HEPATECTOMY\n\nNEURO: UNABLE TO ASSES DUE TO PARALYTIC/SEDATIVE, BUT WELL PARALYZED.\nPUPILS REACT. DOES NOT APPEAR TO BE IN ANY DISCOMFORT.\n\nCARDIO: HR STABLE WITH RATE 88-90 CONSISTENTLY AND WITHOUT ECTOPICS. CARDIAC OUTPUT HIGH W/LOW SVR'S; LEVO DOSE UNCHANGED @ 0.48 KEEPING SYSTOLIC BP > 100 PER DR.\n\nRESP: ACIDOTIC. PAO2 IMPROVED BUT ON HIGH LEVEL O2. SUCTIONED FOR MINIMUM AND RELUCTANT TO AGGRESSIVELY SUCTION DO TO SEVERE COAGULOPATHY\n\nGU/GI: CVVHD RESTARTED AFTER MULTIPLE ATTEMPTS TO REINSERT QUINTON CATH NOW ON (R) FEM SITE. GOAL IS TO PULL OFF FLUID AND NOT ATTEMPT TO WEAN PRESSORS. IN INCREMENTS OF 50ML PFR INCREASED TO 200. SEE FLOW SHEET FOR CC DETAILS BUT BP REMAINED OVER 100 SYSTOLIC\n\nBLOOD PRODUCTS FOR LAST 24HR: 6AM-6AM\nI PRBC, 7FFP, 3 PLATELETS.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-08-13 00:00:00.000", "description": "Report", "row_id": 1596414, "text": "resp care note\n\npartially compensated metabolic acidosis with severe hypoxemia. Pt on CVVH all night. able to wean FiO2 to 70% this A.M.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-11 00:00:00.000", "description": "Report", "row_id": 1596405, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT VERY ILL. TEAM IN FOR EGD. PT WITH LARGE AMT BLOOD AND 3 VARICIES BANDED. HCT DOWN TO 23 DESPITE BLOOD TX. RAPID INFUSER USED AND MULTI UNITS PRBC'S, FFP AND CRYO GIVEN. HCT IMPROVED. PT WITH SEVERE HYPOTENSION.MULTI FLUID BOLUSES GIVEN. PRESSORS STARTED. CURRENTLY ON LEVO AND VASOPRESSIN. ALINE, CVL, AND SWAN PLACED. PT ALSO WITH ACIDOSIS. SEVERAL AMPS BICARB GIVEN AND THEN BICARB GTT STARTED. LYTES ABNORMAL AND ATTEMT MADE TO CORRECT. SEE FLOWSHEET. PT ALSO PARALYZED AND SEDATED ON CISAT AND FENT GTTS. SANDOSTATIN GTT ALSO STARTED. ABD NOW FIRM AND VERY DISTENDED. PT WITH SM AMT DARK BLOODY STOOL. PT ALSO WITH LARGE AMT BLOOD FROM NOSE AND MOUTH. TEAM AWARE. HOB 30 DEGRESS TO PREVENT ASPIRATION. BUN/CREAT ELEVATED AND NO U/O ALL NOC. TEAM AWARE. PT'S FAMILY IN TO SEE PT AND SPENT NOC IN WAITING ROOM. CLERGY UP TO SEE PT AT FAMILY'S REQUEST.\n\nA/P-PT REMAINS CRITICALLY ILL. CON'T CURRNET PLAN.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2133-08-11 00:00:00.000", "description": "Report", "row_id": 1596406, "text": "Resp Care Note:\n\nPt cont intub with OETT sedated/paralyzed and on mech vent as per Carevue. Lung sounds ess clear but absent at bases. ABGs metabolic acidosis with oxygen deficit; vent adjusted accordingly. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-11 00:00:00.000", "description": "Report", "row_id": 1596407, "text": "Pt remains intubated and on mechanical ventilation settings of A/C 34/450/10peep/80%. BS: Ess clear. Sx for small amts of thick pale yellow secretions. 02 sats in high 90's. ABG's remains acidotic. Plan is to cont mechanical ventilation and make changes accordingly with ABG's results.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-11 00:00:00.000", "description": "Report", "row_id": 1596408, "text": "condition update\nNeuro: Pt is on cisat/fentanyl gtt, unable to obtain twitchs with tof since late pm, ? accuracy d/t anasarca. Pt tolerating vent./general care. Pt does not open eyes, yet will make attempt to wiggle toes/squeeze hand to command. No spontaneous movements. Pupils are equal and reactive.\nCV: NSR, vasopressin/levophed titrated to keep map>60. Afeb., bear hugger for low temp. Received 5 units ffp and 1 unit platlets to correct coagulopathy, 2 units PRBC to correct hct. Ca+ repleted.\nResp: Vent changed - increased to 10 PEEP, otherwise remains on CMV, Fi02 80%. LS clear and diminished in the bases.\nGI: NPO, copious amts brb from nose/mouth, large amt. tarry stool with clots x's 1. Abd. firm/distended. Bladder pressure 25-28. BS absent.\nGU: anuric, CVVH initiated, PFR @ 50, pt does not tolerate increase.\nPlan: Continue blood procucts to correct coagulopathy, hct. Titrate pressors to keep MAP>60. Monitor abg, met. acidosis. CVVH. Replete lytes.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-12 00:00:00.000", "description": "Report", "row_id": 1596409, "text": "Resp Care Note:\n\nPt cont intub with OETT sedated/paralyzed and on mech vent and CAVH as per Carevue. Lung sounds dim @ bases. ABGs demonstrated PaO2 and pH trending down and PaCO2 up; vent adjusted accordingly. Pt's PIP increases with small Vt changes and he needs a Ve~17LPM to maintain an adequate PaCO2. Oxygenation cont to be a concern due to derecruitment of lungs esp @ bases. Pt will probably require more PEEP soon. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-10 00:00:00.000", "description": "Report", "row_id": 1596404, "text": "PT ADMITTED FROM 10 WITH GI BLEEDING, HAS RECEIVED FFP ON FLOOR, IS RECEIVING TWO UNITS PRBC HERE IN SICU.,\n\nNEURO; A&OX3, SLIGHTLY ANXIOUS, MAE, FOLLOWS COMMANDS,\n\nCARDIOVASCULAR; HR 90'S-SR, SYS BP 120-99,\n\nRESPIR; LUNGS CLEAR, ON N/C AT 2L/MIN, 02 SAT 98%, ? INTUBATING FOR EGDPROCEDURE\n\nPLAN; COMPLETE TWO PRBC, CHECK CBC AND LYTES AFTER, ? CENTRAL LINE AND A LINE, EGD PLANNED, ? INTUBATING PRIOR TO PROCEDURE\n\n" }, { "category": "Nursing/other", "chartdate": "2133-08-15 00:00:00.000", "description": "Report", "row_id": 1596422, "text": "Resp Care\nPt remains intubated #7.5 ett, 23@lip, bs bil diminished. Vent settings currently PCV 42 x 30 100% +25. ABGs remain w/ met acidosis. Plan to continue with vent support at this time.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-15 00:00:00.000", "description": "Report", "row_id": 1596423, "text": "NURSING UPDATE\nCV:\n STARTING @ 0445, PT PRESENTED WITH MULTIPLE EPISODES OF BRADY BIGEMINY, W/FLEETING LOSS OF PULSE AND BP. RX WITH ATROPINE, CACL, AND BICARB. 0535 - VFIB, DEFIB 360J X1, CONVERTED NSR BUT ASYSTOLIC AFTER 1 MIN. ATROPINE X2, EPI X2 AND BICARB. @ 0545 PEA, EPI, ATROPINE BICARB, D50% 1AMP AND INSULIN 10U. CONVERTED TO SR. TRANSFUSED WITH 1U PRBC'S AND 1U CRYO. RHYTHM CONTINUED IN AND OUT OF BIGEMINY. INCREASINGLY HYPOTENSIVE @ 0630. LEVOPHED MAX DOSED, NEO RESTARTED AND MAX DOSED. PT NOT RESPONDING. FAMILY SEEN BY DR ...PT NOW DNR. @ 0710, BRADY RHYTHM RETURNED, FAMILY CALLED TO BEDSIDE. PT ASYSTOLIC - TIME OF DEATH 0720.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-13 00:00:00.000", "description": "Report", "row_id": 1596415, "text": "Pt cont to be mechancially ventilated. Pt switched to PCV ventilation. PIP's now 38-40. Insp Pressure 39. I-time .80 RR 34 FI02 100%. 15peep. Suctioned small amts of pale yellow thick secretions. 02 sats in mid 90's. Pt cont to be in metabolic acidosis. CVVH cont all day. Plan is to cont on PSV ventilation and monitor ABG's accordingly.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-14 00:00:00.000", "description": "Report", "row_id": 1596420, "text": "Please see carevue for specifics.\n\nNeuro: Grimaces when eyes touched, no response to nailbed pressure on all four ext. Fentanyl gtt at 25mcg/hr. PERL, does not follow commands, no spont movement.\n\nCardio: NSR, no ectopy, generalized edema. CI 1.90, CO 5.35, CVP 18-20, SBP low 80's to 70's with Levo at .50mcg/kg/min. ok to increase Levo to .90 for fluid removal via CVVHDF. Levo currently at 0.90mcg/kg/min with SBP 100-120's. Vasopres at .12units. Goal SBP >100.\n\nResp: Multiple vent chnages throughout day, see carevue for details. Remains metabolic acidotic. LS diminished bil at bases and clear upper lobes. PaO2 60-70's with FiO2 .80. O2sat goal 90-93.\n\nEndo: Blood glucose 60-80 receiving 50%Dextrose every hour to every other hour.\n\nGI: hypoactive to absent BSX4, abd is obese. No GI access, started TPN this evening. Octreotide gtt 50mcg/hr.\n\nGU: foley, anuric.\n\nSKIN: right upper lobe OA with scant amounts of sero/sang drainage, repacked with NS W-D. Lower right quad incision draining scant amount of sero fluid, DSD reapplied.\n\nCRRT: CVVHDF with fluid goal removal of as much as can tolerate. Filter starting to clot. Quinton right fem. Ca++ gtt sliding scale.\n\nPOC: Offer emotional support to wife, children, friends, and family. Continue to remove as much fluid as possible via CVVHDF. Monitor skin integrity, continue to monitor hemodynamics and resp status.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-13 00:00:00.000", "description": "Report", "row_id": 1596416, "text": "Please see carevue for specifics.\n\nNeuro: Cisa dc'd. PERL, does not follow commands, no spont movement. Fentanyl gtt at 50mcg/hr.\n\nCardio: NSR 80-90's, no ectopy. Generalized edema. 3uPRBC, 4uFFP today. To receive Factor seven this evening for increasing INR. CVP 23-29, CO 13, Cardiac index 4.63. Swan not to be wedge due to coags. SBP upper 80-90's. Levo 0.50mcg/kg/min and Vaso 0.12units.\n\nCVVHDF continueous throughout day with goal to remove fluid and keeping SBP about 95-100, see carevue for specifics.\n\nRespir: Multi vent changes throughout the day, see Carevue for specifics. Remains metabolic acidotic.\n\nEndo: Pt requiring 50%dextrose every hour to every other hour for glucoses in the 40-60's.\n\nGI: Abd obese, hypoactive BSx4,\n\nGU: Foley, no urine output.\n\nSKIN: small open areas on scrotum leaking sero fluid. Unable to roll pt due to being unstable with SBP throughout day. At 1700 pt spit out of mouth a large clot witnesses by team.\n\nPOC: Continue CVVHDF, monitor hemodynamics, offer emotional support to family, continue blood products.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-14 00:00:00.000", "description": "Report", "row_id": 1596417, "text": "condition update\nS/P HEPATIC RESECTION; SEPSIS AND VARICEAL BLEED NOW W/COMPLICATED POST-OP COURSE.\nNEURO: OFF PARALYTICS BUT REMAINS ON FENTANYL (RATE DECREASED TO 25MCG) REACTS TO STIMULI\n\nCARDIO: IN JUNCTIONAL RTHYMN. RATE 80'S . BP STABLE ON .5 MCG/KG/MIN OF LEVO. NO ATTEMPTS MADE TO WEAN AS SUGGESTED BY TEAMS. FOCUS HAS BEEN TO REMOVE FLUID VIA CRRT.\n\nRESP: INTUBATED ON PCV W/FIO2 @ 100% AND POOR OXYGENATION. CS DIMINISHED IN BASES BUT OTHERWISE CLEAR, QUESTIONABLE ASPIRATION.\n\nCRRT: FLUID REMOVAL WORKING WELL BUT STILL HAS ELEVATED LACTATE LEVELS\n CHANGED PATIENT TO BARI-MAXX 11 BED TO MINIMIZE ISSUES W/LONG TERM MOBILITY.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-14 00:00:00.000", "description": "Report", "row_id": 1596418, "text": "Pt still has very severe metbolic acidosid and hypoxemia. He is on PSV with driving pressure of 24, peep 15, 100% RR set 34. numerous mode trials yesterday did not improve pt vent or acid base status, APRC ventilation was attempted but pt quickly became hypotensive.\n" }, { "category": "Nursing/other", "chartdate": "2133-08-14 00:00:00.000", "description": "Report", "row_id": 1596419, "text": "Respiratory Therapy\nPt remains orally intubated on full mechanical support. Remains on PCV w/ Pinsp = 42, RR = 26, I:E = 1:1.3, PEEP = +25, Driving pressure = 17. Multiple vent changes made to attempt to improve oxygenation in order to start decreasing FiO2. Inverse ratio tried this AM w/out significant effect. Recruitment breaths x3 on APRV Phigh = 35, Plow = 32, Thigh = 30, Tlow = 0.5 resulting in PaO2 88. Able to wean FiO2 to .80%. ABG shows severe metabolic acidosis w/ acceptable oxygenation. SpO2 high 80s-low 90s. Plateau pressure = 36, Mean airway pressure = 33. ETT remains secure/patent & in good position. See resp flowsheet for specific vent settings/data/multiple vent changes/ABG results.\n\nPlan: maintain full ventilatory support...\n" }, { "category": "Nursing/other", "chartdate": "2133-08-15 00:00:00.000", "description": "Report", "row_id": 1596421, "text": "NURSING UPDATE\nCV/HEME:\n AT , HR BECAME IRREGULAR WITH VARYING COMPLEXES THEN BRADY DOWN TO RATE IN 40'S. DR ATTENDED IMMEDIATELY. ATROPINE 1AMP IV X1, RATE ELEVATED TO 140'S SVT, SBP IN 60'S. 1L NS IV BOLUS AND NEO GTTS STARTED. PULSE PALPATION FLEETING. CARDIOVERTED WITH 100J/200J/300JX2/360JX2, BEFORE LAST SHOCK, RHYTHM WOULD CONVERT TO SR BUT NOT SUSTAIN FOR MORE THAN SECS, AFTER LAST SHOCK PT MAINTAINED SR. CA GLUC GTTS INCREASED AND MAG 2G IV X1. BICARB 4 AMPS IVP X4 DURING EVENT, AND BICARB GTTS STARTED. AMIODARONE 300MG IV BOLUS FOLLOWED BY AMIO GTTS 1MG/MIN X 6H THEN REDUCED TO 0.5MG/MIN.\n AT 2230, HR BECAME IRREGULAR AGAIN, VENT BIGEMINY W/RATE IN 40'S, AMP ATROPINE AND 1 AMP BICARB IVP, EPISODE RESOLVED.\n INR HIGH 5.8, FFP 1U FOLLOWED BY FFP GTTS @ 40CC/H, INCREASED TO 80CC/H @ 0130.\n HCT LOW @ 26.9, TRANSFUSED WITH 1U PRBC'S, FOLLOW UP HCT LEVEL PENDING.\n PLTS LOW @ 35, TRANSFUSED WITH 1 BAG PLTS, FOLLOW UP PLT 54.\n 1 BAG CRYO TRANSFUSED FOR LOW FIBRINOGEN OF 65.\n\nHEPATORENAL:\n ANURIC. CRRT CONT IN CVVHDF MODE. NO FLUID REMOVAL FOR SEVERAL HOURS POST CODE. RESTARTED PFR AND INCREASING AMOUNT Q1H AS PT TOLERATES.\n\nNEURO:\n NO SPONTANEOUS MOVEMENT. PUPILS 4MM NON-REACTIVE SINCE CODE, MD'S AWARE. ?POSSIBLY EFFECT OF NOT CLEARING ATROPINE?\n\nSOCIAL:\n FAMILY AND FRIENDS IN WAITING ROOM, IMMEDIATE FAMILY AND PASTOR VISITING BEDSIDE AT FREQUENT INTERVALS.\n\n" }, { "category": "Echo", "chartdate": "2133-08-06 00:00:00.000", "description": "Report", "row_id": 78739, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 74\nWeight (lb): 400\nBSA (m2): 2.92 m2\nBP (mm Hg): 140/72\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 15:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\nLV wall motion abnormality cannot be fully excluded. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is moderately dilated. The left ventricular cavity size is\nnormal. Due to suboptimal technical quality, a focal wall motion abnormality\ncannot be fully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThere is no aortic valve stenosis. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. There is no pericardial effusion.\n\nNo vegetation seen but cannot exclude.\n\nCompared with the prior study (tape reviewed) of , there is no\ndefinite change but images are technically suboptimal for comparison.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-08-03 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 875713, "text": " 2:59 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: S/P LIVER RESECTION; EVAL FOR HEMMORHAGE; ABD PAIN\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p liver biopsy now with ab pain\n REASON FOR THIS EXAMINATION:\n eval for hemmorhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: VK MON 3:37 PM\n No intraperitoneal hemorrhage. Small amt ascites. Abscess in hepatic resection\n site.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 48-year-old post-liver nodule resection. The patient is now\n post-liver biopsy, assess for hemorrhage.\n\n TECHNIQUE: VCT images of the abdomen and pelvis without IV contrast.\n\n COMPARISON: .\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Atelectatic changes are seen at the\n right lung base. There is a small right pleural effusion. The patient is\n post-hepatic nodule resection with numerous clips seen in the right lobe of\n the liver in the region of segment 5. There is also a 2.8 x 2.2 cm\n collection with air and debris within it in the region of the nodule\n resection. This extends approximately 6 cm in the craniocaudad dimension. An\n external drainage catheter is seen coursing adjacent to this, but not within\n it. The liver itself is nodular in appearance consistent with cirrhosis. The\n spleen, pancreas, adrenals, and kidneys are unremarkable. There is a small\n amount of free fluid within the abdomen. There is no evidence of\n intraperitoneal hemorrhage. Small lymph nodes are seen scattered throughout\n the mesentery. There is no free air.\n\n CT PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid, and bladder are\n unremarkable. The distal ureters are not seen. Small amount of free fluid is\n seen within the pelvis. There is no pathologic pelvic or inguinal\n lymphadenopathy.\n\n The soft tissues demonstrate marked stranding consistent with anasarca. The\n osseous structures demonstrate degenerative changes in the lower thoracic and\n lumbar spine.\n\n IMPRESSION:\n\n No intraperitoneal hemorrhage. Small collection within the prior hepatic\n nodule resection site. This likely represent omental or gelfoam packing. If\n there is no history of packing, this could represent a small abscess. Please\n correlate clinically. Small amount of ascites and anasarca.\n\n (Over)\n\n 2:59 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: S/P LIVER RESECTION; EVAL FOR HEMMORHAGE; ABD PAIN\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2133-08-10 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 876547, "text": " 10:28 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: Fluid collection, infection? USE ORAL CONTRAST PLEASE\n Admitting Diagnosis: RT UPPER QUADRANT ABSCESS\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p liver biopsy now with ab pain, wbc 45K, RF- NO IV\n CONTRAST!!!\n REASON FOR THIS EXAMINATION:\n Fluid collection, infection? USE ORAL CONTRAST PLEASE\n CONTRAINDICATIONS for IV CONTRAST:\n RF;RF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver mass resection, leukocytosis, question fluid\n collection, infection.\n\n COMPARISON: CT abdomen and pelvis dated .\n\n TECHNIQUE: Multidetector CT scanning was performed from the level of the lung\n bases to the level of the pubic symphysis with oral contrast only. Coronal\n and sagittal reformations were obtained.\n\n CT OF THE ABDOMEN: There has been interval increase in the right-sided\n pleural effusion, as well as development of a small left-sided pleural\n effusion. The visualized portion of the mediastinum is unremarkable. In the\n liver, again noted are multiple surgical clips. In the right lobe, again seen\n is the collection of gas and debris measuring approximately 19 x 28 x 55 mm,\n stable since the prior exam. There has been interval removal of a drain.\n Again noted is a collection posterior to segment 6 and 7, which is similar in\n size to the prior exam. The liver is nodular in contour, consistent with\n cirrhosis. The patient is status post cholecystectomy. The spleen, adrenal\n glands, and pancreas are unremarkable in appearance. There is an interval\n increase in the ascites. There is no free air. Note is made of a midline\n soft tissue defect. There is shotty mesenteric lymphadenopathy, which does\n not meet pathologic criteria for enlargement. The vascular structures are\n unremarkable on this noncontrast scan. Incidental note is made of\n gynecomastia.\n\n CT OF THE PELVIS: The bladder, prostate, and rectum are unremarkable in\n appearance. There is no pathologic pelvic or inguinal lymphadenopathy. There\n is no free fluid.\n\n The osseous structures demonstrate a well-corticated fragment adjacent to the\n right superior ramus, which was present on the prior exam. There are no lytic\n or sclerotic lesions noted.\n\n IMPRESSION:\n 1. Interval increase in the size of pleural effusions as well as abdominal\n ascites.\n 2. Stable appearance to the collection adjacent to the area of surgery as\n (Over)\n\n 10:28 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: Fluid collection, infection? USE ORAL CONTRAST PLEASE\n Admitting Diagnosis: RT UPPER QUADRANT ABSCESS\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n well as the collection posterior to the right lobe. The former are most\n likely represents Gelfoam packing. The latter may be amenable to IR guided\n drainage if clinically indicated.\n\n These findings were communicated to Alacka on at 3:45\n p.m.\n\n" }, { "category": "Radiology", "chartdate": "2133-08-11 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 876775, "text": " 9:38 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o infiltrate, effusion, trali.\n Admitting Diagnosis: RT UPPER QUADRANT ABSCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48yo M w/ liver failure, GI bleed. hypoxia.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, effusion, trali.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old male with liver failure, rule out infiltrate or\n effusion.\n\n TECHNIQUE: AP supine chest radiograph from , is compared with\n AP supine chest radiograph from .\n\n Allowing for technique, the endotracheal tube is unchanged from prior exam.\n The tip of the right subclavian catheter is difficult to visualize; however,\n it appears to project over the SVC. There is a persistent right lung\n opacification, which likely represents a combination of pleural effusion and\n pulmonary edema. There is vascular engorgement of the left pulmonary artery.\n The left lung is otherwise clear. The cardiac, mediastinal, and hilar\n contours are otherwise unchanged from prior exam.\n\n IMPRESSION:\n 1. Persistent moderate-sized right pleural effusion with associated pulmonary\n edema.\n 2. Engorged left pulmonary artery.\n\n" }, { "category": "ECG", "chartdate": "2133-08-11 00:00:00.000", "description": "Report", "row_id": 211108, "text": "Sinus rhythm. T wave inversions in leads III and aVF - cannot exclude ischemia.\nCompared to the previous tracing of T wave changes are new.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429678, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, nightsweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he travelled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to Glouchester on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible ecephalitis. He was persistently\n febrile to 102. At 0500 am , he had a generalized tonic clonic\n seizure lating 45 seconds and desaturated to the low 80s. ABG at that\n time was 7.05/38/60. The patient was then intubated. CXR showed no\n infiltrate.\n Precautions: Pt on seizure and fall precautions.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd on 60 of propofol. Pt unresponsive this am, although withdrew to\n painful stimuli & not following commands. Propofol stopped this am\n for 10minutes\n pt opened eyes briefly, otherwise there was no change\n in MS. Pupils were Pinpoint b/l and sluggish\nICU team informed.\n Action:\n Propofol stopped for 30 minutes during bedside EEG. LP done this\n evening.\n Response:\n No seizure activity noted, occasional myoclonic tremors to b/l LEs and\n b/l UEs. Pt opening eyes, following commands inconsistently, pupils\n equal Lt eye sluggish, rt eye briskly reactive. Inconsistently nodding\n to yes/no questions. Moving all extremities on bed.\n Plan:\n Cont to monitor MS, seizure & fall precautions, plan for MRI/MRA.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 100.8 rectally.\n Action:\n Tyelenol po given. Sputum cx was sent last night. Ceftriaxone added to\n broad spectrum antibiotics.\n Response:\n No change.\n Plan:\n Cont to monitor temp curve, tyelenol as needed, f/u on cultures\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on AC 40%/500x16/5+, LS rhonchorous to b/l apices, clear to b/l\n bases. Possible aspiration pna when seized. Sxn\nd for thick yellow\n secretions. Copious white oral secretions, Strong productive cough.\n Action:\n Given MDIs.\n Response:\n No change\n Plan:\n Wean vent as tolerated following MRI, cont antibiotic regimen, MDIs.\n" }, { "category": "Respiratory ", "chartdate": "2175-01-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 429743, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details. Weaned to cpap/ ips. Pt slightly anxious.RSBI done on 0 peep/\n 5 ips 28. Appears to understand. Follows commands. MDI\nS given prn.\n Will cont to monitor resp status. Plan to wean to extubate.\n" }, { "category": "Physician ", "chartdate": "2175-01-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429752, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 02:00 PM\n LUMBAR PUNCTURE - At 04:30 PM\n CSF CULTURE - At 05:00 PM\n ARTERIAL LINE - STOP 05:50 PM\n MAGNETIC RESONANCE IMAGING - At 01:03 AM\n .\n -secretions remain high\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 AM\n Acyclovir - 10:00 PM\n Vancomycin - 10:15 PM\n Ampicillin - 12:33 AM\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.4\nC (97.5\n HR: 86 (78 - 100) bpm\n BP: 128/82(91) {112/62(74) - 141/85(96)} mmHg\n RR: 9 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 8,913 mL\n 317 mL\n PO:\n TF:\n IVF:\n 8,703 mL\n 317 mL\n Blood products:\n Total out:\n 3,192 mL\n 650 mL\n Urine:\n 3,192 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,721 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 100%\n ABG: ///28/\n Ve: 8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 10.9 g/dL\n 103 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 108 mEq/L\n 142 mEq/L\n 31.3 %\n 8.9 K/uL\n [image002.jpg]\n 07:58 PM\n 03:29 AM\n 03:30 AM\n 03:58 PM\n 04:13 AM\n WBC\n 20.0\n 16.7\n 8.9\n Hct\n 37.0\n 32.9\n 31.3\n Plt\n 437\n 379\n 306\n Cr\n 1.7\n 1.7\n 1.4\n 1.1\n TCO2\n 29\n Glucose\n 140\n 116\n 122\n 103\n Other labs: PT / PTT / INR:14.7/30.3/1.3, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:79.9 %, Lymph:15.2 %, Mono:3.2 %,\n Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:40 PM\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2175-01-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429753, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 02:00 PM\n LUMBAR PUNCTURE - At 04:30 PM\n CSF CULTURE - At 05:00 PM\n ARTERIAL LINE - STOP 05:50 PM\n MAGNETIC RESONANCE IMAGING - At 01:03 AM\n .\n -secretions remain high\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 AM\n Acyclovir - 10:00 PM\n Vancomycin - 10:15 PM\n Ampicillin - 12:33 AM\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.4\nC (97.5\n HR: 86 (78 - 100) bpm\n BP: 128/82(91) {112/62(74) - 141/85(96)} mmHg\n RR: 9 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 8,913 mL\n 317 mL\n PO:\n TF:\n IVF:\n 8,703 mL\n 317 mL\n Blood products:\n Total out:\n 3,192 mL\n 650 mL\n Urine:\n 3,192 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,721 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 100%\n ABG: ///28/\n Ve: 8 L/min\n Physical Examination\n General Appearance: intubated, sedated, but responsive to voice, does\n not follow commands, withdraws to painful stimuli\n Eyes / Conjunctiva: PERRL, anicteric\n Head, Ears, Nose, Throat: Normocephalic, ET/OG tubes in place\n Lymphatic: Cervical WNL, Supraclavicular WNL, R axillary LN approx 1cm\n in size\n Cardiovascular: RRR S1S2 no m/r/g\n Peripheral Vascular: warm, well perfused 2+dp pulses\n Respiratory / Chest: clear bilaterally while supine. Notable is mild\n swelling in L chest (breast) no erythema.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: no cyanosis, no edema, no rashes\n Neurologic: Sedated. Opens eyes to voice but does not follow commands,\n Responds to: Noxious stimuli, Withdraws all extremities to painful\n stimuli, R>L. Fatiguable clonus in feet bilat, R>L. plantar downgoing\n bilat. 2+ relexes symmetric throughout.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 10.9 g/dL\n 103 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 108 mEq/L\n 142 mEq/L\n 31.3 %\n 8.9 K/uL\n [image002.jpg]\n 07:58 PM\n 03:29 AM\n 03:30 AM\n 03:58 PM\n 04:13 AM\n WBC\n 20.0\n 16.7\n 8.9\n Hct\n 37.0\n 32.9\n 31.3\n Plt\n 437\n 379\n 306\n Cr\n 1.7\n 1.7\n 1.4\n 1.1\n TCO2\n 29\n Glucose\n 140\n 116\n 122\n 103\n Other labs: PT / PTT / INR:14.7/30.3/1.3, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:79.9 %, Lymph:15.2 %, Mono:3.2 %,\n Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # Fevers: Persistently high fevers in setting of myalgias, sore throat\n raises suspicion for viral prodrome and infection. Altered mental\n status and seizure x1 also causes concern for meningitis vs.\n encephalitis. The patient had LP at OSH but per neuro service would be\n useful to tap again and run for various viral serologies and infectious\n labs. CSF at OSH not consistent with bacterial infection. CXR appears\n clear w/question of haziness in LLL. Clinically lungs are clear on exam\n but noted this AM was increased sputum production, and sample was sent\n for culture. Given patient\ns history he is at increased risk for HIV\n (study pending at OSH). In addition to infectious causes (including\n HIV, EBV, HSV, Cryptococcus, etc) etiologies such as vasculitis and\n malignancy should be considered.\n - MRI/MRA to further work up anatomy and ? vasculitis\n - cont acyclovir, vancomycin, ampicillin, ceftriaxone for infectious\n etiology\n - repeat LP in am for cell count, protein, glucose, HSV PCR, HIV, Lyme,\n west PCR, enterovirus PCR\n - f/u stool cultures\n - f/u HIV labs\n -f/u ID and neurology recommendations\n - f/u blood cultures, urine culture and sputum cultures\n .\n # Respiratory failure: intubated in the setting of seizure with\n metabolic acidosis. CXR without significant pulmonary pathology\n although increasing sputum production.\n - RSBI, SBT qam\n - albuterol/atrovent nebs\n -if increasing secretions would hold off on extubation\n .\n # Seizures: Consider toxic-metabolic vs infectious etiology vs.\n structural abdormality of focus. Ct negative at outside hospital. MRI\n to be done today. Per neurology will start keppra and monitor for\n seizure activity with EEG.\n - check MRI\n - keppra\n - propofol drip for sedation\n - ativan prn for seizures\n -monitor and replete electrolytes\n -tox screen negative except for marijuana\n .\n # Altered mental status: given high fevers, altered mental status, and\n results of LP, suspect encephalitis. At OSH had no other evidence of\n infection. Tox + for cannaboids but unlikely to cause persistent\n altered MS. Also noted by family was change in behavior from his\n baseline since his return from overseas. Will continue to work up for\n toxic/metabolic and infectious etiologies.\n - fever treatment as above\n - f/u neuro consult\n - renal failure treatment as below\n .\n # ARF: At OSH, initial Cr 1.5 and improved this am to 1.2. Now again\n elevated to 1.7. Presumably had normal renal function prior. Initial\n ARF likely due to dehydration due to poor po intake and increased\n insensible losses from fevers. Also suspect acyclovir may have caused\n intrinsic renal damage.\n - aggressive IVF\n - renally dose meds\n - trend Cr\n -spin urine if ? acyclovir damage\n .\n # Sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration. Much better this morning.\n - IVF as above\n - monitor fever curve\n - ID treatment as above\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: NPO for now, replete electrolytes prn, nutrition recs if\n prolonged intubation.\n -monitor INR (1.5), may need vitamin K if concern for bleed\n .\n # PPx: heparin sc. PPI while on vent. bowel regimen\n .\n # ACCESS: PIV x 3, aline\n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: ICU\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:40 PM\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2175-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429756, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Altered mental status (not Delirium)\n Assessment:\n Received patient sedated with propofol 60mcg/kg/min, awake, nodding\n head for yes or no, following commands inconsistently. Moving all\n extremities, trying to reach to ETT,bilateral wrist restraints in place\n for safety. Both pupils reacting to light\n Action:\n Propofol increased to 80mcg/kg/min to keep the patient comfortable\n with vent, MRI head done\n Response:\n Patient easily arousable with sedation, following commands, No seizure\n activity noted\n Plan:\n F/U the results of MRI, LP, continue with antibiotics, neuro check q2-4\n hrs, continue on keppra\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp\n Action:\n Antibiotics given\n Response:\n Plan:\n Tylenol PRN, monitor temp curve, F/U culture results\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient sedated, vented on A/C mode 500/16/5 and 40%,\n bilateral lung sound clear and occasionally rhonchorous and cleared\n with suction. Copious amount of oral secreation, gag/cough intact\n Action:\n Increased sedation to keep comfortable with ETT, suction PRN, MDI\n .Tolerating SBT in am\n Response:\n O2 sats 98-100%, continue to be off sedation\n Plan:\n Wean sedation and SBT in AM, for possible extubation\n" }, { "category": "Nursing", "chartdate": "2175-01-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430040, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 70 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH:\n Additional history: H/O lyme disease in \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:88\n Temperature:\n 97.4\n Arterial BP:\n S:139\n D:79\n Respiratory rate:\n 33 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 673 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:26 AM\n Potassium:\n 3.9 mEq/L\n 04:26 AM\n Chloride:\n 104 mEq/L\n 04:26 AM\n CO2:\n 31 mEq/L\n 04:26 AM\n BUN:\n 6 mg/dL\n 04:26 AM\n Creatinine:\n 1.0 mg/dL\n 04:26 AM\n Glucose:\n 111 mg/dL\n 04:26 AM\n Hematocrit:\n 35.2 %\n 04:26 AM\n Finger Stick Glucose:\n 129\n 04:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with: family (mother)\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to:\n Date & time of Transfer: \n History: Mr. is a 36 year old healthy male with recent travel\n to who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate. Pt was extubated on . Remains on RA with\n sat 98-100%, no c/o of SOB.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2175-01-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430041, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 70 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH:\n Additional history: H/O lyme disease in \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:88\n Temperature:\n 97.4\n Arterial BP:\n S:139\n D:79\n Respiratory rate:\n 33 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 673 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:26 AM\n Potassium:\n 3.9 mEq/L\n 04:26 AM\n Chloride:\n 104 mEq/L\n 04:26 AM\n CO2:\n 31 mEq/L\n 04:26 AM\n BUN:\n 6 mg/dL\n 04:26 AM\n Creatinine:\n 1.0 mg/dL\n 04:26 AM\n Glucose:\n 111 mg/dL\n 04:26 AM\n Hematocrit:\n 35.2 %\n 04:26 AM\n Finger Stick Glucose:\n 129\n 04:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with: family (mother)\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to:\n Date & time of Transfer: \n History: Mr. is a 36 year old healthy male with recent travel\n to who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate. Pt was extubated on . Remains on RA with\n sat 98-100%, no c/o of SOB.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2175-01-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430042, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 70 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH:\n Additional history: H/O lyme disease in \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:88\n Temperature:\n 97.4\n Arterial BP:\n S:139\n D:79\n Respiratory rate:\n 33 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 673 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:26 AM\n Potassium:\n 3.9 mEq/L\n 04:26 AM\n Chloride:\n 104 mEq/L\n 04:26 AM\n CO2:\n 31 mEq/L\n 04:26 AM\n BUN:\n 6 mg/dL\n 04:26 AM\n Creatinine:\n 1.0 mg/dL\n 04:26 AM\n Glucose:\n 111 mg/dL\n 04:26 AM\n Hematocrit:\n 35.2 %\n 04:26 AM\n Finger Stick Glucose:\n 129\n 04:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with: family (mother)\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to:\n Date & time of Transfer: \n History: Mr. is a 36 year old healthy male with recent travel\n to who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate. Pt was extubated on early AM. Remains on\n RA with sat 98-100%, no c/o of SOB.\n Altered mental status (not Delirium)\n Assessment:\n Pt is currently A + O x 3. Follows all commands, PERRL, EOMI, MAEs.\n Slight difficulty w/ fine motor tasks (eg managing breakfast)\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt running low grade temp today, t max this afternoon 100.7 F oral. No\n sz activity today.\n Action:\n Tylenol x 1 given 650 mg.\n Response:\n Temp decreased to 99.1 F.\n Plan:\n Cont to tx pt for likely viral infex causing encephalitis: acyclovir\n and keppra.\n" }, { "category": "Nursing", "chartdate": "2175-01-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430044, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 70 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH:\n Additional history: H/O lyme disease in \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:88\n Temperature:\n 97.4\n Arterial BP:\n S:139\n D:79\n Respiratory rate:\n 33 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 673 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:26 AM\n Potassium:\n 3.9 mEq/L\n 04:26 AM\n Chloride:\n 104 mEq/L\n 04:26 AM\n CO2:\n 31 mEq/L\n 04:26 AM\n BUN:\n 6 mg/dL\n 04:26 AM\n Creatinine:\n 1.0 mg/dL\n 04:26 AM\n Glucose:\n 111 mg/dL\n 04:26 AM\n Hematocrit:\n 35.2 %\n 04:26 AM\n Finger Stick Glucose:\n 129\n 04:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with: family (mother)\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to:\n Date & time of Transfer: \n History: Mr. is a 36 year old healthy male with recent travel\n to who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate. Pt was extubated on early AM. Remains on\n RA with sat 98-100%, no c/o of SOB.\n Altered mental status (not Delirium)\n Assessment:\n Pt is currently A + O x 3. Follows all commands, PERRL, EOMI, MAEs.\n Slight difficulty w/ fine motor tasks (eg managing breakfast) and\n problem solving, but able to recall\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt running low grade temp today, t max this afternoon 100.7 F oral. No\n sz activity today.\n Action:\n Tylenol x 1 given 650 mg.\n Response:\n Temp decreased to 99.1 F.\n Plan:\n Cont to tx pt for likely viral infex causing encephalitis: acyclovir\n and keppra.\n" }, { "category": "Nursing", "chartdate": "2175-01-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430046, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 70 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH:\n Additional history: H/O lyme disease in \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:88\n Temperature:\n 97.4\n Arterial BP:\n S:139\n D:79\n Respiratory rate:\n 33 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 673 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:26 AM\n Potassium:\n 3.9 mEq/L\n 04:26 AM\n Chloride:\n 104 mEq/L\n 04:26 AM\n CO2:\n 31 mEq/L\n 04:26 AM\n BUN:\n 6 mg/dL\n 04:26 AM\n Creatinine:\n 1.0 mg/dL\n 04:26 AM\n Glucose:\n 111 mg/dL\n 04:26 AM\n Hematocrit:\n 35.2 %\n 04:26 AM\n Finger Stick Glucose:\n 129\n 04:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with: family (mother)\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to:\n Date & time of Transfer: \n History: Mr. is a 36 year old healthy male with recent travel\n to who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate. Pt was extubated on early AM. Remains on\n RA with sat 98-100%, no c/o of SOB. Most recently pt has been afebrile\n w/ clearing MS. neg for bacterial to cause encephalitis,\n more likely viral.\n Altered mental status (not Delirium)\n Assessment:\n Pt is currently A + O x 3. Follows all commands, PERRL, EOMI, MAEs.\n Slight difficulty w/ fine motor tasks (eg managing items on breakfast\n tray) and problem solving, but able to recall distant and recent events\n more clearly.\n Action:\n Freq neuro checks, bed alarm on. Freq re-orientation.\n Response:\n Pt is free from declining MS.\n :\n Cont to tx encephalitis and monitor MS.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt afebrile throughout last night and today, T max 98.3 F oral.\n Action:\n Admin Acyclovir for presumed viral insult causing encephalitis.\n Response:\n Pt cont\ns to be afebrile.\n Plan:\n Cont to tx pt for likely viral infex: acyclovir and keppra. Poss VNA\n home visits for continuation of IV acyclovir pending final lab\n results. Cont keppra s/p discharge home for sz prophylaxis.\n" }, { "category": "Physician ", "chartdate": "2175-01-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 430060, "text": "Chief Complaint:\n 24 Hour Events:\n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 10:00 AM\n Pt attempted to get out of bed and pulled on foley catheter. This RN\n removed foley b/c pt c/o bladder spasm/pain.\n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 12:00 PM\n Pt pulled out \n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 05:00 PM\n Pt pulled out , replaced w/20 gauge\n - extubated in AM\n - MRI/MRA - normal\n - remains on Acyclovir, d/c'd other antibitoics\n - ID recs - cont Acyclovir, awaiting MRI\n - Neuro - continue Keppra, defer to ID\n - ADAT\n - no issues overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 06:26 AM\n Vancomycin - 08:30 AM\n Ceftriaxone - 10:30 AM\n Acyclovir - 10:16 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 07:40 PM\n Heparin Sodium (Prophylaxis) - 10:17 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 36.3\nC (97.4\n HR: 86 (70 - 103) bpm\n BP: 137/86(98) {124/41(25) - 159/101(107)} mmHg\n RR: 28 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,384 mL\n 563 mL\n PO:\n 500 mL\n TF:\n IVF:\n 2,884 mL\n 563 mL\n Blood products:\n Total out:\n 3,810 mL\n 550 mL\n Urine:\n 3,810 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -426 mL\n 13 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 198 (198 - 198) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n FiO2: 40%\n SpO2: 96%\n ABG: ///31/\n Ve: 6.5 L/min\n Physical Examination\n General Appearance: alert and oriented, pleasant and interactive\n Eyes / Conjunctiva: PERRL, anicteric,\n Head, Ears, Nose, Throat: Normocephalic, MMM\n Cardiovascular: RRR S1S2 no m/r/g\n Peripheral Vascular: warm, well perfused 2+dp pulses\n Respiratory / Chest: clear bilaterally.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: no cyanosis, no edema, no rashes\n Neurologic: AOX3, CN II-XII intact, sensation intact, 5/5 strength in\n upper and lower extremities,\n Labs / Radiology\n 395 K/uL\n 12.4 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 6 mg/dL\n 104 mEq/L\n 141 mEq/L\n 35.2 %\n 8.1 K/uL\n [image002.jpg]\n 07:58 PM\n 03:29 AM\n 03:30 AM\n 03:58 PM\n 04:13 AM\n 04:26 AM\n WBC\n 20.0\n 16.7\n 8.9\n 8.1\n Hct\n 37.0\n 32.9\n 31.3\n 35.2\n Plt\n 437\n 379\n 306\n 395\n Cr\n 1.7\n 1.7\n 1.4\n 1.1\n 1.0\n TCO2\n 29\n Glucose\n 140\n 116\n 122\n 103\n 111\n Other labs: PT / PTT / INR:14.1/29.2/1.2, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:79.9 %, Lymph:15.2 %, Mono:3.2 %,\n Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # Fevers: Has been afebrile for almost 24hours, low grade temp\n yesterday afternoon. Patient has several labs pending but at this point\n bacterial meningitis has been ruled out and antibiotics have been\n d/c\nd. Acyclovir needs to be continued until HSV labs return. This is\n likely viral in etiology. MRI/MRA were negative, CSF negative to date,\n crypto Ag neg, HIV ag negative.\n - MRI/MRA negative\n - cont acyclovir pending HSV\n - f/u ID recs\n - f/u stool cultures\n - f/u blood cultures, urine culture and sputum cultures\n -currently pending: WNV, EEE, VDRL, HSV, enterovirus, stool cx, RPR,\n , ANCA\n .\n # Respiratory failure: extubated and doing well, tolerating po\n .\n # Seizures: has not had seizure-like activity since admission. Per\n neuro, may need to stay on keppra for the time being.\n - keppra\n -f/u neuro recs and if there is endpoint to keppra treatment\n -daily neuro exam\n .\n # Altered mental status: significantly improved over last two days,\n likely due to fevers, infection as well as sedation.\n -continue to monitor\n .\n # ARF: Improved with IV hydration. Likely a combination of pre-renal\n dehydration and acyclovir therapy.\n - IVF bolus w/acyclovir\n - renally dose meds\n - trend Cr\n .\n # Sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration. Improved\n - IVF as above\n - monitor fever curve\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: ADAT, replete electrolytes prn\n .\n # PPx: if ambulating/moving no need for heparin sc. PPI while on vent.\n d/c bowel regimen given diarrhea\n .\n # ACCESS: , \n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: c/o to medical floor\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2175-01-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430064, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 70 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH:\n Additional history: H/O lyme disease in \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:88\n Temperature:\n 97.4\n Arterial BP:\n S:139\n D:79\n Respiratory rate:\n 33 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 673 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:26 AM\n Potassium:\n 3.9 mEq/L\n 04:26 AM\n Chloride:\n 104 mEq/L\n 04:26 AM\n CO2:\n 31 mEq/L\n 04:26 AM\n BUN:\n 6 mg/dL\n 04:26 AM\n Creatinine:\n 1.0 mg/dL\n 04:26 AM\n Glucose:\n 111 mg/dL\n 04:26 AM\n Hematocrit:\n 35.2 %\n 04:26 AM\n Finger Stick Glucose:\n 129\n 04:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with: family (mother)\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to:\n Date & time of Transfer: \n History: Mr. is a 36 year old healthy male with recent travel\n to who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate. Pt was extubated on early AM. Remains on\n RA with sat 98-100%, no c/o of SOB. Most recently pt has been afebrile\n w/ clearing MS. neg for bacterial to cause encephalitis,\n more likely viral.\n Altered mental status (not Delirium)\n Assessment:\n Pt is currently A + O x 3. Follows all commands, PERRL, EOMI, MAEs.\n Slight difficulty w/ fine motor tasks (eg managing items on breakfast\n tray) and problem solving, but able to recall distant and recent events\n more clearly.\n Action:\n Freq neuro checks, bed alarm on. Freq re-orientation.\n Response:\n Pt is free from declining MS.\n :\n Cont to tx encephalitis and monitor MS.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt afebrile throughout last night and today, T max 98.3 F oral.\n Action:\n Admin Acyclovir for presumed viral insult causing encephalitis.\n Response:\n Pt cont\ns to be afebrile.\n Plan:\n Cont to tx pt for likely viral infex: acyclovir and keppra. Poss VNA\n home visits for continuation of IV acyclovir pending final lab\n results. Cont keppra s/p discharge home for sz prophylaxis.\n" }, { "category": "Nursing", "chartdate": "2175-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429939, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt is A + O x 2, can state name and place, confused to time. . PERRL,\n MAEs normal strength, follows commands consistently but needs freq\n redirection. Cannot understand how to use call light. Pt\n intermittently pulling ECG leads, BP cuff despite explanation.\n Action:\n Bed low, locked, alarm on. Freq neuro checks, reorientation. PIV\n replaced (covered w/ arm ), pt voiding w/ urinal in bed.\n Response:\n Pt is free from falls. Head MRI found no evidence of abnormality.\n Plan:\n Freq asses MS, cont to tx for infection, and cx\n" }, { "category": "Physician ", "chartdate": "2175-01-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 430065, "text": "Chief Complaint:\n 24 Hour Events:\n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 10:00 AM\n Pt attempted to get out of bed and pulled on foley catheter. This RN\n removed foley b/c pt c/o bladder spasm/pain.\n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 12:00 PM\n Pt pulled out \n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 05:00 PM\n Pt pulled out , replaced w/20 gauge\n - extubated in AM\n - MRI/MRA - normal\n - remains on Acyclovir, d/c'd other antibitoics\n - ID recs - cont Acyclovir, awaiting MRI\n - Neuro - continue Keppra, defer to ID\n - ADAT\n - no issues overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 06:26 AM\n Vancomycin - 08:30 AM\n Ceftriaxone - 10:30 AM\n Acyclovir - 10:16 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 07:40 PM\n Heparin Sodium (Prophylaxis) - 10:17 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 36.3\nC (97.4\n HR: 86 (70 - 103) bpm\n BP: 137/86(98) {124/41(25) - 159/101(107)} mmHg\n RR: 28 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,384 mL\n 563 mL\n PO:\n 500 mL\n TF:\n IVF:\n 2,884 mL\n 563 mL\n Blood products:\n Total out:\n 3,810 mL\n 550 mL\n Urine:\n 3,810 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -426 mL\n 13 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 198 (198 - 198) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n FiO2: 40%\n SpO2: 96%\n ABG: ///31/\n Ve: 6.5 L/min\n Physical Examination\n General Appearance: alert and oriented, pleasant and interactive\n Eyes / Conjunctiva: PERRL, anicteric,\n Head, Ears, Nose, Throat: Normocephalic, MMM\n Cardiovascular: RRR S1S2 no m/r/g\n Peripheral Vascular: warm, well perfused 2+dp pulses\n Respiratory / Chest: clear bilaterally.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: no cyanosis, no edema, no rashes\n Neurologic: AOX3, CN II-XII intact, sensation intact, 5/5 strength in\n upper and lower extremities,\n / Radiology\n 395 K/uL\n 12.4 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 6 mg/dL\n 104 mEq/L\n 141 mEq/L\n 35.2 %\n 8.1 K/uL\n [image002.jpg]\n 07:58 PM\n 03:29 AM\n 03:30 AM\n 03:58 PM\n 04:13 AM\n 04:26 AM\n WBC\n 20.0\n 16.7\n 8.9\n 8.1\n Hct\n 37.0\n 32.9\n 31.3\n 35.2\n Plt\n 437\n 379\n 306\n 395\n Cr\n 1.7\n 1.7\n 1.4\n 1.1\n 1.0\n TCO2\n 29\n Glucose\n 140\n 116\n 122\n 103\n 111\n Other : PT / PTT / INR:14.1/29.2/1.2, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:79.9 %, Lymph:15.2 %, Mono:3.2 %,\n Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # Fevers: Has been afebrile for almost 24hours, low grade temp\n yesterday afternoon. Patient has several pending but at this point\n bacterial meningitis has been ruled out and antibiotics have been\n d/c\nd. Acyclovir needs to be continued until HSV return. This is\n likely viral in etiology. MRI/MRA were negative, CSF negative to date,\n crypto Ag neg, HIV ag negative.\n - MRI/MRA negative\n - cont acyclovir pending HSV\n - f/u ID recs\n - f/u stool cultures\n - f/u blood cultures, urine culture and sputum cultures\n -currently pending: WNV, EEE, VDRL, HSV, enterovirus, stool cx, RPR,\n , ANCA\n .\n # Respiratory failure: extubated and doing well, tolerating po\n .\n # Seizures: has not had seizure-like activity since admission. Per\n neuro, may need to stay on keppra for the time being.\n - keppra\n -f/u neuro recs and if there is endpoint to keppra treatment\n -daily neuro exam\n .\n # Altered mental status: significantly improved over last two days,\n likely due to fevers, infection as well as sedation.\n -continue to monitor\n .\n # ARF: Improved with IV hydration. Likely a combination of pre-renal\n dehydration and acyclovir therapy.\n - IVF bolus w/acyclovir\n - renally dose meds\n - trend Cr\n .\n # Sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration. Improved\n - IVF as above\n - monitor fever curve\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: ADAT, replete electrolytes prn\n .\n # PPx: if ambulating/moving no need for heparin sc. PPI while on vent.\n d/c bowel regimen given diarrhea\n .\n # ACCESS: , \n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: c/o to medical floor\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 36 year old male without significant past\n medical history presented initially to OSH , transferred to \n on with fevers, altered mental status, seizures and respiratory\n failure. W/u appears most c/w viral encephalopathy. ID and neuro\n following. Extubated successfully yesterday. Remains on acyclovir.\n Confusion improving.\n EXAM: TM 100.7 \nAF 97.4 137/86 HR 78 RR 12 96% RA\n WDWN M, alert and oriented, remains confused though improved from\n yesterday, no JVD, CTA, RR, benign abd, no edema, nonfocal neuro\n : WBC 8.1 Hct 35, inr 1.2 K 3.9 cr 1.0 na 141\n HIV viral load neg\n CSF--crypto ag neg, HSV PCR pending, viral pending,\n /anca pending\n Blood cx pending\n MRI brain-neg\n A/P: has made significant progress. Continues to improve from mental\n status standpoint but remains slightly confused. Fever curve has\n improved now af since yesterday afternoon. WBC ct normalized. No\n evidence of pna on cxr. Remains on acyclovir w/ bacterial CSF coverage\n d/c\nd yesterday. Additional viral work-up remains pending. Continuing\n keppra for szs prophy given increased risk in setting of viral\n process/encephalitis. ARF (? component related to acyclovir) has\n resolved and cr remains stable with good u/o. Will encourgae PO\n hydration as remains on acyclovir. Had small amts diarrhea likely from\n bowel reg--d/c colace--if persists would check C diff. Consult PT.\n Stable for floor transfer.\n Time spent: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:27 PM ------\n" }, { "category": "Nursing", "chartdate": "2175-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429916, "text": "History: Mr. is a 36 year old healthy male with recent travel\n to who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Events: Pt was extubated this AM at 0630 w/o incident. Pt is\n currently on RA Sp02 95-100%, RR mid 20s.\n Altered mental status (not Delirium)\n Assessment:\n Pt is A + O x 2, can state name and place, confused to time. Pt cannot\n recall events leading to OSH admission up until present. PERRL, EOMI,\n MAEs normal strength, follows commands consistently but needs freq\n redirection. Cannot understand how to use call light. Foley cath\n removed this AM when pt attempted to get OOB and pulled it. Pt pulled\n out 2 PIVs today.\n Action:\n Bed low, locked, alarm on. Freq neuro checks, reorientation. PIV\n replaced (covered w/ arm ), pt voiding w/ urinal in bed.\n Response:\n Pt is free from falls.\n Plan:\n Freq asses MS, cont to tx for infection, await MRI results and cx\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt running low grade temp today, t max this afternoon 100.7 F oral. No\n sz activity today.\n Action:\n Tylenol x 1 given 650 mg.\n Response:\n Plan:\n Cont to tx pt for likely viral infex causing encephalitis: acyclovir\n and keppra.\n" }, { "category": "Nursing", "chartdate": "2175-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429917, "text": "History: Mr. is a 36 year old healthy male with recent travel\n to who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Events: Pt was extubated this AM at 0630 w/o incident. Pt is\n currently on RA Sp02 95-100%, RR mid 20s. LS CTAB.\n Altered mental status (not Delirium)\n Assessment:\n Pt is A + O x 2, can state name and place, confused to time. Pt cannot\n recall events leading to OSH admission up until present. PERRL, EOMI,\n MAEs normal strength, follows commands consistently but needs freq\n redirection. Cannot understand how to use call light. Foley cath\n removed this AM when pt attempted to get OOB and pulled it. Pt pulled\n out 2 PIVs today.\n Action:\n Bed low, locked, alarm on. Freq neuro checks, reorientation. PIV\n replaced (covered w/ arm ), pt voiding w/ urinal in bed.\n Response:\n Pt is free from falls.\n Plan:\n Freq asses MS, cont to tx for infection, await MRI results and cx\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt running low grade temp today, t max this afternoon 100.7 F oral. No\n sz activity today.\n Action:\n Tylenol x 1 given 650 mg.\n Response:\n Temp decreased to 99.1 F.\n Plan:\n Cont to tx pt for likely viral infex causing encephalitis: acyclovir\n and keppra.\n" }, { "category": "Nursing", "chartdate": "2175-01-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 430017, "text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 70 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH:\n Additional history: H/O lyme disease in \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:88\n Temperature:\n 97.4\n Arterial BP:\n S:139\n D:79\n Respiratory rate:\n 33 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 673 mL\n 24h total out:\n 950 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:26 AM\n Potassium:\n 3.9 mEq/L\n 04:26 AM\n Chloride:\n 104 mEq/L\n 04:26 AM\n CO2:\n 31 mEq/L\n 04:26 AM\n BUN:\n 6 mg/dL\n 04:26 AM\n Creatinine:\n 1.0 mg/dL\n 04:26 AM\n Glucose:\n 111 mg/dL\n 04:26 AM\n Hematocrit:\n 35.2 %\n 04:26 AM\n Finger Stick Glucose:\n 129\n 04:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with: family (mother)\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to:\n Date & time of Transfer: \n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2175-01-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429536, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:39 PM\n start time is approximate\n BLOOD CULTURED - At 08:00 PM\n PAN CULTURE - At 10:30 PM\n EKG - At 10:49 PM\n ARTERIAL LINE - START 12:28 AM\n FEVER - 101.3\nF - 07:47 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 11:08 PM\n Vancomycin - 12:09 AM\n Ampicillin - 12:09 AM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.5\nC (99.5\n HR: 97 (97 - 112) bpm\n BP: 106/61(75) {100/61(75) - 113/67(80)} mmHg\n RR: 16 (16 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 389 mL\n 1,865 mL\n PO:\n TF:\n IVF:\n 389 mL\n 1,865 mL\n Blood products:\n Total out:\n 910 mL\n 520 mL\n Urine:\n 910 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -521 mL\n 1,345 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.40/45/238/26/2\n Ve: 7.3 L/min\n PaO2 / FiO2: 476\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 379 K/uL\n 12.1 g/dL\n 116 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 10 mg/dL\n 105 mEq/L\n 138 mEq/L\n 32.9 %\n 16.7 K/uL\n [image002.jpg]\n 07:58 PM\n 03:29 AM\n 03:30 AM\n WBC\n 20.0\n 16.7\n Hct\n 37.0\n 32.9\n Plt\n 437\n 379\n Cr\n 1.7\n 1.7\n TCO2\n 29\n Glucose\n 140\n 116\n Other labs: PT / PTT / INR:15.8/28.6/1.4, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:89.3 %, Lymph:6.2 %, Mono:3.8 %,\n Eos:0.7 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:40 PM\n 18 Gauge - 08:00 PM\n Arterial Line - 12:28 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2175-01-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429538, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:39 PM\n start time is approximate\n BLOOD CULTURED - At 08:00 PM\n PAN CULTURE - At 10:30 PM\n EKG - At 10:49 PM\n ARTERIAL LINE - START 12:28 AM\n FEVER - 101.3\nF - 07:47 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 11:08 PM\n Vancomycin - 12:09 AM\n Ampicillin - 12:09 AM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.5\nC (99.5\n HR: 97 (97 - 112) bpm\n BP: 106/61(75) {100/61(75) - 113/67(80)} mmHg\n RR: 16 (16 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 389 mL\n 1,865 mL\n PO:\n TF:\n IVF:\n 389 mL\n 1,865 mL\n Blood products:\n Total out:\n 910 mL\n 520 mL\n Urine:\n 910 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -521 mL\n 1,345 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.40/45/238/26/2\n Ve: 7.3 L/min\n PaO2 / FiO2: 476\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 379 K/uL\n 12.1 g/dL\n 116 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 10 mg/dL\n 105 mEq/L\n 138 mEq/L\n 32.9 %\n 16.7 K/uL\n [image002.jpg]\n 07:58 PM\n 03:29 AM\n 03:30 AM\n WBC\n 20.0\n 16.7\n Hct\n 37.0\n 32.9\n Plt\n 437\n 379\n Cr\n 1.7\n 1.7\n TCO2\n 29\n Glucose\n 140\n 116\n Other labs: PT / PTT / INR:15.8/28.6/1.4, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:89.3 %, Lymph:6.2 %, Mono:3.8 %,\n Eos:0.7 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # fevers: given persistent high fevers, altered mental status,\n seizures, and LP results, suspect aseptic meningioencephalitis. CSF\n studies not c/w bacterial infection. Significant leukocytosis with\n left shift raises concern for bacterial process although could be\n stress response from recent seizure. Ddx of aseptic\n meningioencephalitis includes viral (HSV, enterovirus, HIV, west ,\n VZV, mumps), vasculitis, malignancy. ? exposure to toxin in \n leading to encephalitis. At OSH HIV negative, RPR negative, crypto CSF\n negative.\n - MRI\n - cont empiric acyclovir at 10 mg/kg Q8H\n - cont empiric ceftriaxone. Would add vancomycin to cover possible PCN\n resistent strep and ampicillin to cover listeria although no reason to\n suspect immunocompromised\n - repeat LP in am for cell count, protein, glucose, HSV PCR, HIV, Lyme,\n west PCR, enterovirus PCR\n - stool culture for enteric viruses\n - check HIV Ab, HIV VL, CD4\n - consider serologic testing for cocksackie, echovirus, west , EBV,\n Lyme\n - send blood cultures, U/A, urine culture\n - check CXR\n - sputum and stool cultures prn\n - consider placing PPD\n - droplet precautions\n .\n # respiratory failure: intubated in the setting of seizure with\n metabolic acidosis. CXR without significant pulmonary pathology.\n - RSBI, SBT qam\n - albuterol/atrovent nebs\n .\n # seizures: possibly due to irritable focus from infection or anatomic\n abnormality. EtOH history unclear so must also consider EtOH withdrawal\n seizures although seems less likely in current setting. Discussed with\n Neuro. In setting of acute illness and single isolated seizure, no need\n for prophylaxis.\n - check MRI\n - folate/thiamine\n - propofol drip for sedation with have some effect on EtoH withdrawal\n ppx\n - ativan prn for seizures\n .\n # altered mental status: given high fevers, altered mental status, and\n results of LP, suspect encephalitis. At OSH had no other evidence of\n infection. Tox + for cannaboids but unlikely to cause persistent\n altered MS. Could have used other illicit drugs in although\n was 2 weeks ago so doubt persistent effects. Could also be subclinical\n seizures. Also toxic metabolic encephalopathy.\n - fever treatment as above\n - Neuro consult in am\n - renal failure treatment as below\n .\n # ARF: At OSH, initial Cr 1.5 and improved this am to 1.2. Now again\n elevated to 1.7. Presumably had normal renal function prior. Initial\n ARF likely due to dehydration due to poor po intake and increased\n insensible losses from fevers. Now suspect new process. ? contribution\n of acyclovir.\n - aggressive IVF\n - urine lytes\n - urine eos\n - trend Cr\n .\n # sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration.\n - IVF as above\n - tylenol prn for fevers\n - ID treatment as above\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: NPO for now\n - nutrition recs for ? TFs as may have prolonged intubation\n .\n # PPx: heparin sc. PPI while on vent. bowel regimen\n .\n # ACCESS: PIV x 3\n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: ICU\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:40 PM\n 18 Gauge - 08:00 PM\n Arterial Line - 12:28 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2175-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429735, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Altered mental status (not Delirium)\n Assessment:\n Received patient sedated with propofol 60mcg/kg/min, awake, nodding\n head for yes or no, following commands inconsistently. Moving all\n extremities, trying to reach to ETT,bilateral wrist restraints in place\n for safety. Both pupils reacting to light\n Action:\n Propofol increased to 80mcg/kg/min to keep the patient comfortable\n with vent, MRI head done\n Response:\n Patient easily arousable with sedation, following commands, No seizure\n activity noted\n Plan:\n F/U the results of MRI, LP, continue with antibiotics, neuro check q2-4\n hrs, continue on keppra\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp\n Action:\n Antibiotics given\n Response:\n Plan:\n Tylenol PRN, monitor temp curve, F/U culture results\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient sedated, vented on A/C mode 500/16/5 and 40%,\n bilateral lung sound clear and occasionally rhonchorous and cleared\n with suction. Copious amount of oral secreation, gag/cough intact\n Action:\n Increased sedation to keep comfortable with ETT, suction PRN, MDI\n Response:\n O2 sats 98-100%\n Plan:\n Wean sedation and SBT in AM, for possible extubation\n" }, { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429657, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, nightsweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he travelled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to Glouchester on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible ecephalitis. He was persistently\n febrile to 102. At 0500 am , he had a generalized tonic clonic\n seizure lating 45 seconds and desaturated to the low 80s. ABG at that\n time was 7.05/38/60. The patient was then intubated. CXR showed no\n infiltrate.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd on 60 of propofol. Pt unresponsive this am, although withdrew to\n painful stimuli & not following commands. Propofol stopped this am\n for 10minutes\n pt opened eyes briefly, otherwise there was no change\n in MS. Pupils were Pinpoint b/l and sluggish\nICU team informed.\n Action:\n Propofol stopped for 30 minutes during bedside EEG.\n Response:\n No seizure activity noted, occasional tremors to b/l LEs and b/l UEs.\n Pt opening eyes, following commands inconsistently, pupils equal Lt eye\n sluggish, rt eye briskly reactive. Inconsistently nodding to yes/no\n questions. Moving all extremities on bed.\n Plan:\n Cont to monitor MS, seizure & fall precautions, plan for MRI/MRA.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 100.8 rectally.\n Action:\n Tyelenol po given. Sputum cx was sent last night. Ceftriaxone added to\n broad spectrum antibiotics.\n Response:\n No change.\n Plan:\n Cont to monitor temp curve, tyelenol as needed, f/u on cultures\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on AC 40%/500x16/5+, LS clear, CXR showing potential haziness to\n LLL. Infrequently sxn\nd for thick tan secretions. Copious white oral\n secretions, Strong cough.\n Action:\n Given MDIs.\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2175-01-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 429658, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2175-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429721, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Altered mental status (not Delirium)\n Assessment:\n Received patient sedated with propofol 60mcg/kg/min, awake, nodding\n head for yes or no, following commands inconsistently. Moving all\n extremities, trying to reach to ETT,bilateral wrist restraints in place\n for safety. Both pupils reacting to light\n Action:\n Propofol increased to 80mcg/kg/min to keep the patient comfortable\n with vent, MRI head done\n Response:\n Patient easily arousable with sedation, following commands,\n Plan:\n F/U the results of MRI, LP, continue with antibiotics, neuro check q2-4\n hrs\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp\n Action:\n Antibiotics given\n Response:\n Plan:\n Tylenol PRN, monitor temp curve, F/U culture results\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2175-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429726, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. According to family, patient had\n been in his USOH until returning from . The day following his\n return, , he developed high fevers, as high as 104, typically\n beginning in the late afternoon and occurred daily. He had significant\n chills, night sweats, decreased appetite and po intake, and was\n awakening at night with nightmares and talking in his sleep which was\n atypical for him. He did have one episode of diarrhea on . While\n in he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea. He then apparently drove from to on\n . He was pulled over by the police for driving erratically and\n was then send to Hospital after providing bizarre\n answers to police. According to EMS who transported him, he could not\n answer any questions appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.3 up on admission to MICU, wbc 20, lactate 1.6, STachy, OSH\n LP which showed 6 wbc,s,18 rbc.glucose 73,Tp 47. treated with\n ceftriaxone and acyclovir for possible encephalitis\n Action:\n Cold bath given, Tylenol po given, pan cultured\n Response:\n Temp down to 99.5, lactate 0.9\n Plan:\n Continue monitor temp curve/labs, F/U culture results, continue\n antibiotics\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated for airway protection from OSH after blood gas of\n 7.05/38/60 after seizure activity. Sedated with propofol and vented, on\n A/C 16/500/5 amd 50%.. Bilateral lung sounds clear.\n Action:\n Vented, a line placed, ETT suction with small amount of thick yellow\n secreation\n Response:\n Blood gas satisfactory, o2 sats 99-100%\n Plan:\n Lighten sedation and SBT in am, but patient is awaiting for MRI of head\n Altered mental status (not Delirium)\n Assessment:\n Patient was sedated with propofol and intubated from OSH, unable to\n assess for orientation, withdraws to pain and grimacing face, not\n following commands, ? myoclonic jerky movements noted on especially to\n lt hand. Occasionally eyes open to voice. Pupils both 3mm and reacting\n to light. Head CT neg\n Action:\n Neuro check, awaiting MRI\n Response:\n Continue to be sedated, Neuro unchanged, good gag and cough\n Plan:\n Continue to monitor neuro, F/U culture results, repeat LP for further\n studies\n" }, { "category": "Nursing", "chartdate": "2175-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429794, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Altered mental status (not Delirium)\n Assessment:\n Received patient sedated with propofol 60mcg/kg/min, awake, nodding\n head for yes or no, following commands inconsistently. Moving all\n extremities, trying to reach to ETT,bilateral wrist restraints in place\n for safety. Both pupils reacting to light\n Action:\n Propofol increased to 80mcg/kg/min to keep the patient comfortable\n with vent, MRI head done\n Response:\n Patient easily arousable with sedation, following commands, No seizure\n activity noted, sedation off, more awake, following commands.\n Plan:\n F/U the results of MRI, LP, continue with antibiotics, neuro check q2-4\n hrs, continue on keppra\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp\n Action:\n Antibiotics given\n Response:\n Plan:\n Tylenol PRN, monitor temp curve, F/U culture results\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient sedated, vented on A/C mode 500/16/5 and 40%,\n bilateral lung sound clear and occasionally rhonchorous and cleared\n with suction. Copious amount of oral secreation, gag/cough intact\n Action:\n Increased sedation to keep comfortable with ETT, suction PRN, MDI\n .Tolerating SBT in am, Tolerated SBT, seen by MD, following commands,\n sedation off, extubated at 0650hrs.\n 0650Response:\n O2 sats 98-100%, on 2l nasal canula\n Plan:\n Continue to monitor resp status\n" }, { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429503, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429644, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, nightsweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he travelled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to Glouchester on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd on 60 of propofol. Pt unresponsive this am, although withdrew to\n painful stimuli & not following commands. Propofol stopped this am\n for 10minutes\n pt opened eyes briefly, otherwise there was no change\n in MS. Pupils were Pinpoint b/l and sluggish\nICU team informed.\n Action:\n Propofol stopped for 30 minutes during bedside EEG.\n Response:\n No seizure activity noted, occasional tremors to b/l LEs and b/l UEs.\n Pt opening eyes, following commands inconsistently, pupils equal Lt\n sluggish, rt briskly reactive. Inconsistently nodding to yes/no\n questions. Moving all extremities.\n Plan:\n Cont to monitor MS, seizure precautions, plan for MRI/MRA.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 100.8 rectally.\n Action:\n No tyelenol given at this time. Sputum cx was sent last night.\n Ceftriaxone added to broad spectrum antibiotics.\n Response:\n No change.\n Plan:\n Cont to monitor temp curve, tyelenol as needed, f/u on cultures\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on AC 40%/500x16/5+, LS clear, CXR showing potential haziness to\n LLL. Infrequently sxn\nd for thick tan secretions. Copious white oral\n secretions, Strong cough.\n Action:\n Given MDIs.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429645, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, nightsweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he travelled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to Glouchester on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible ecephalitis. He was persistently\n febrile to 102. At 0500 am , he had a generalized tonic clonic\n seizure lating 45 seconds and desaturated to the low 80s. ABG at that\n time was 7.05/38/60. The patient was then intubated. CXR showed no\n infiltrate.\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd on 60 of propofol. Pt unresponsive this am, although withdrew to\n painful stimuli & not following commands. Propofol stopped this am\n for 10minutes\n pt opened eyes briefly, otherwise there was no change\n in MS. Pupils were Pinpoint b/l and sluggish\nICU team informed.\n Action:\n Propofol stopped for 30 minutes during bedside EEG.\n Response:\n No seizure activity noted, occasional tremors to b/l LEs and b/l UEs.\n Pt opening eyes, following commands inconsistently, pupils equal Lt\n sluggish, rt briskly reactive. Inconsistently nodding to yes/no\n questions. Moving all extremities.\n Plan:\n Cont to monitor MS, seizure precautions, plan for MRI/MRA.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 100.8 rectally.\n Action:\n No tyelenol given at this time. Sputum cx was sent last night.\n Ceftriaxone added to broad spectrum antibiotics.\n Response:\n No change.\n Plan:\n Cont to monitor temp curve, tyelenol as needed, f/u on cultures\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on AC 40%/500x16/5+, LS clear, CXR showing potential haziness to\n LLL. Infrequently sxn\nd for thick tan secretions. Copious white oral\n secretions, Strong cough.\n Action:\n Given MDIs.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2175-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429717, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429505, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429506, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.3 up on admission to MICU, wbc\n lactate 1.6, STachy, OSH LP\n which showed 6 wbc,s,18 rbc.glucose 73,Tp 47. treated with ceftriaxone\n and acyclovir for possible encephalitis\n Action:\n Cold bath given, Tylenol po given, pan cultured\n Response:\n Plan:\n Continue monitor temp curve/labs, F/U culture results, continue\n antibiotics\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429508, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. According to family, patient had\n been in his USOH until returning from . The day following his\n return, , he developed high fevers, as high as 104, typically\n beginning in the late afternoon and occurred daily. He had significant\n chills, night sweats, decreased appetite and po intake, and was\n awakening at night with nightmares and talking in his sleep which was\n atypical for him. He did have one episode of diarrhea on . While\n in he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea. He then apparently drove from to on\n . He was pulled over by the police for driving erratically and\n was then send to Hospital after providing bizarre\n answers to police. According to EMS who transported him, he could not\n answer any questions appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.3 up on admission to MICU, wbc\n lactate 1.6, STachy, OSH LP\n which showed 6 wbc,s,18 rbc.glucose 73,Tp 47. treated with ceftriaxone\n and acyclovir for possible encephalitis\n Action:\n Cold bath given, Tylenol po given, pan cultured\n Response:\n Plan:\n Continue monitor temp curve/labs, F/U culture results, continue\n antibiotics\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated for airway protection from OSH after blood gas of\n 7.05/38/60 after seizure activity. Sedated with propofol and vented, on\n A/C 16/500/5 amd 50%.. Bilateral lung sounds clear.\n Action:\n Vented, a line placed, ETT suction with small amount of thick yellow\n secreation\n Response:\n Plan:\n Lighten sedation and SBT in am\n Altered mental status (not Delirium)\n Assessment:\n Patient was sedated with propofol and intubated from OSH, unable to\n assess for orientation, withdraws to pain and grimacing face, not\n following commands, ? myoclonic jerky movements noted on especially to\n lt hand. Occasionally eyes open to voice. Pupils both 3mm and reacting\n to light. Head CT neg\n Action:\n Neuro check, awaiting MRI\n Response:\n Continue to be sedated, Neuro unchanged, good gag and cough\n Plan:\n Continue to monitor neuro, F/U culture results, repeat LP for further\n studies\n" }, { "category": "Respiratory ", "chartdate": "2175-01-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 429517, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: no\n Procedure location: osh\n Reason: airway protection\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: abg 7.40/45/238/26 MRI trip this am\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429519, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. According to family, patient had\n been in his USOH until returning from . The day following his\n return, , he developed high fevers, as high as 104, typically\n beginning in the late afternoon and occurred daily. He had significant\n chills, night sweats, decreased appetite and po intake, and was\n awakening at night with nightmares and talking in his sleep which was\n atypical for him. He did have one episode of diarrhea on . While\n in he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea. He then apparently drove from to on\n . He was pulled over by the police for driving erratically and\n was then send to Hospital after providing bizarre\n answers to police. According to EMS who transported him, he could not\n answer any questions appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.3 up on admission to MICU, wbc 20, lactate 1.6, STachy, OSH\n LP which showed 6 wbc,s,18 rbc.glucose 73,Tp 47. treated with\n ceftriaxone and acyclovir for possible encephalitis\n Action:\n Cold bath given, Tylenol po given, pan cultured\n Response:\n Temp down to 99.5, lactate 0.9\n Plan:\n Continue monitor temp curve/labs, F/U culture results, continue\n antibiotics\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient intubated for airway protection from OSH after blood gas of\n 7.05/38/60 after seizure activity. Sedated with propofol and vented, on\n A/C 16/500/5 amd 50%.. Bilateral lung sounds clear.\n Action:\n Vented, a line placed, ETT suction with small amount of thick yellow\n secreation\n Response:\n Blood gas satisfactory, o2 sats 99-100%\n Plan:\n Lighten sedation and SBT in am, but patient is awaiting for MRI of head\n Altered mental status (not Delirium)\n Assessment:\n Patient was sedated with propofol and intubated from OSH, unable to\n assess for orientation, withdraws to pain and grimacing face, not\n following commands, ? myoclonic jerky movements noted on especially to\n lt hand. Occasionally eyes open to voice. Pupils both 3mm and reacting\n to light. Head CT neg\n Action:\n Neuro check, awaiting MRI\n Response:\n Continue to be sedated, Neuro unchanged, good gag and cough\n Plan:\n Continue to monitor neuro, F/U culture results, repeat LP for further\n studies\n" }, { "category": "Physician ", "chartdate": "2175-01-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429615, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:39 PM\n start time is approximate\n BLOOD CULTURED - At 08:00 PM\n PAN CULTURE - At 10:30 PM\n EKG - At 10:49 PM\n ARTERIAL LINE - START 12:28 AM\n FEVER - 101.3\nF - 07:47 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 11:08 PM\n Vancomycin - 12:09 AM\n Ampicillin - 12:09 AM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.5\nC (99.5\n HR: 97 (97 - 112) bpm\n BP: 106/61(75) {100/61(75) - 113/67(80)} mmHg\n RR: 16 (16 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 389 mL\n 1,865 mL\n PO:\n TF:\n IVF:\n 389 mL\n 1,865 mL\n Blood products:\n Total out:\n 910 mL\n 520 mL\n Urine:\n 910 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -521 mL\n 1,345 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.40/45/238/26/2\n Ve: 7.3 L/min\n PaO2 / FiO2: 476\n Physical Examination\n General Appearance: intubated, sedated, but responsive to voice, does\n not follow commands, withdraws to painful stimuli\n Eyes / Conjunctiva: PERRL, anicteric\n Head, Ears, Nose, Throat: Normocephalic, ET/OG tubes in place\n Lymphatic: Cervical WNL, Supraclavicular WNL, R axillary LN approx 1cm\n in size\n Cardiovascular: RRR S1S2 no m/r/g\n Peripheral Vascular: warm, well perfused 2+dp pulses\n Respiratory / Chest: clear bilaterally while supine. Notable is mild\n swelling in L chest (breast) no erythema.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: no cyanosis, no edema, no rashes\n Neurologic: Sedated. Opens eyes to voice but does not follow commands,\n Responds to: Noxious stimuli, Withdraws all extremities to painful\n stimuli, R>L. Fatiguable clonus in feet bilat, R>L. plantar downgoing\n bilat. 2+ relexes symmetric throughout.\n Labs / Radiology\n 379 K/uL\n 12.1 g/dL\n 116 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 10 mg/dL\n 105 mEq/L\n 138 mEq/L\n 32.9 %\n 16.7 K/uL\n [image002.jpg]\n TSH 0.81 HIV pnd blood cx pnd sputum GPC in pairs urine cx\n pend\n 07:58 PM\n 03:29 AM\n 03:30 AM\n WBC\n 20.0\n 16.7\n Hct\n 37.0\n 32.9\n Plt\n 437\n 379\n Cr\n 1.7\n 1.7\n TCO2\n 29\n Glucose\n 140\n 116\n Other labs: PT / PTT / INR:15.8/28.6/1.4, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:89.3 %, Lymph:6.2 %, Mono:3.8 %,\n Eos:0.7 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n OSH labs: DFA negative, crypto Ag negative, RPR negative, HIV pending,\n HSV PCR pending\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # Fevers: Persistently high fevers in setting of myalgias, sore throat\n raises suspicion for viral prodrome and infection. Altered mental\n status and seizure x1 also causes concern for meningitis vs.\n encephalitis. The patient had LP at OSH but per neuro service would be\n useful to tap again and run for various viral serologies and infectious\n labs. CSF at OSH not consistent with bacterial infection. CXR appears\n clear w/question of haziness in LLL. Clinically lungs are clear on exam\n but noted this AM was increased sputum production, and sample was sent\n for culture. Given patient\ns history he is at increased risk for HIV\n (study pending at OSH). In addition to infectious causes (including\n HIV, EBV, HSV, Cryptococcus, etc) etiologies such as vasculitis and\n malignancy should be considered.\n - MRI/MRA to further work up anatomy and ? vasculitis\n - cont acyclovir, vancomycin, ampicillin, ceftriaxone for infectious\n etiology\n - repeat LP in am for cell count, protein, glucose, HSV PCR, HIV, Lyme,\n west PCR, enterovirus PCR\n - f/u stool cultures\n - f/u HIV labs\n -f/u ID and neurology recommendations\n - f/u blood cultures, urine culture and sputum cultures\n .\n # Respiratory failure: intubated in the setting of seizure with\n metabolic acidosis. CXR without significant pulmonary pathology\n although increasing sputum production.\n - RSBI, SBT qam\n - albuterol/atrovent nebs\n -if increasing secretions would hold off on extubation\n .\n # Seizures: Consider toxic-metabolic vs infectious etiology vs.\n structural abdormality of focus. Ct negative at outside hospital. MRI\n to be done today. Per neurology will start keppra and monitor for\n seizure activity with EEG.\n - check MRI\n - keppra\n - propofol drip for sedation\n - ativan prn for seizures\n -monitor and replete electrolytes\n -tox screen negative except for marijuana\n .\n # Altered mental status: given high fevers, altered mental status, and\n results of LP, suspect encephalitis. At OSH had no other evidence of\n infection. Tox + for cannaboids but unlikely to cause persistent\n altered MS. Also noted by family was change in behavior from his\n baseline since his return from overseas. Will continue to work up for\n toxic/metabolic and infectious etiologies.\n - fever treatment as above\n - f/u neuro consult\n - renal failure treatment as below\n .\n # ARF: At OSH, initial Cr 1.5 and improved this am to 1.2. Now again\n elevated to 1.7. Presumably had normal renal function prior. Initial\n ARF likely due to dehydration due to poor po intake and increased\n insensible losses from fevers. Also suspect acyclovir may have caused\n intrinsic renal damage.\n - aggressive IVF\n - renally dose meds\n - trend Cr\n -spin urine if ? acyclovir damage\n .\n # Sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration. Much better this morning.\n - IVF as above\n - monitor fever curve\n - ID treatment as above\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: NPO for now, replete electrolytes prn, nutrition recs if\n prolonged intubation.\n -monitor INR (1.5), may need vitamin K if concern for bleed\n .\n # PPx: heparin sc. PPI while on vent. bowel regimen\n .\n # ACCESS: PIV x 3, aline\n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: ICU\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:40 PM\n 18 Gauge - 08:00 PM\n Arterial Line - 12:28 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2175-01-20 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 429618, "text": "Subjective\n PT intubated/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n cm\n 70 kg\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n Diagnosis: AMS\n PMH :\n Food allergies and intolerances: NKFA\n Pertinent medications: propofol gtt, bowel meds, thiamin, folate, RISS,\n heparin, abx, others noted\n Labs:\n Value\n Date\n Glucose\n 116 mg/dL\n 03:29 AM\n Glucose Finger Stick\n 141\n 10:00 AM\n BUN\n 10 mg/dL\n 03:29 AM\n Creatinine\n 1.7 mg/dL\n 03:29 AM\n Sodium\n 138 mEq/L\n 03:29 AM\n Potassium\n 4.5 mEq/L\n 03:29 AM\n Chloride\n 105 mEq/L\n 03:29 AM\n TCO2\n 26 mEq/L\n 03:29 AM\n PO2 (arterial)\n 238 mm Hg\n 03:30 AM\n PO2 (venous)\n 127 mm Hg\n 08:03 PM\n PCO2 (arterial)\n 45 mm Hg\n 03:30 AM\n PCO2 (venous)\n 49 mm Hg\n 08:03 PM\n pH (arterial)\n 7.40 units\n 03:30 AM\n pH (venous)\n 7.34 units\n 08:03 PM\n pH (urine)\n 5.0 units\n 10:11 PM\n CO2 (Calc) arterial\n 29 mEq/L\n 03:30 AM\n CO2 (Calc) venous\n 28 mEq/L\n 08:03 PM\n Albumin\n 3.9 g/dL\n 07:58 PM\n Calcium non-ionized\n 8.8 mg/dL\n 03:29 AM\n Phosphorus\n 4.2 mg/dL\n 03:29 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:30 AM\n Magnesium\n 2.7 mg/dL\n 03:29 AM\n ALT\n 19 IU/L\n 07:58 PM\n Alkaline Phosphate\n 66 IU/L\n 07:58 PM\n AST\n 22 IU/L\n 07:58 PM\n Total Bilirubin\n 0.4 mg/dL\n 07:58 PM\n WBC\n 16.7 K/uL\n 03:29 AM\n Hgb\n 12.1 g/dL\n 03:29 AM\n Hematocrit\n 32.9 %\n 03:29 AM\n Current diet order / nutrition support: NPO\n GI: Abd: soft/+bs\n Assessment of Nutritional Status\n Adequately nourished\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: (BEE x or / cal/kg)\n Protein: ( g/kg)\n Fluid:\n Estimation of previous intake: likely Adequate\n Estimation of current intake: Inadequate NPO\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations:\n BG and lyte management as you are\n Please page c/ ?'s #\n" }, { "category": "Nutrition", "chartdate": "2175-01-20 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 429621, "text": "Subjective\n Pt intubated/sedated-no family available\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n cm\n 70 kg\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n Diagnosis: AMS\n PMH : mild asthma, h/o lyme disease in \n Food allergies and intolerances: NKFA\n Pertinent medications: propofol gtt, bowel meds, thiamin, folate, RISS,\n heparin, abx, others noted\n Labs:\n Value\n Date\n Glucose\n 116 mg/dL\n 03:29 AM\n Glucose Finger Stick\n 141\n 10:00 AM\n BUN\n 10 mg/dL\n 03:29 AM\n Creatinine\n 1.7 mg/dL\n 03:29 AM\n Sodium\n 138 mEq/L\n 03:29 AM\n Potassium\n 4.5 mEq/L\n 03:29 AM\n Chloride\n 105 mEq/L\n 03:29 AM\n TCO2\n 26 mEq/L\n 03:29 AM\n PO2 (arterial)\n 238 mm Hg\n 03:30 AM\n PO2 (venous)\n 127 mm Hg\n 08:03 PM\n PCO2 (arterial)\n 45 mm Hg\n 03:30 AM\n PCO2 (venous)\n 49 mm Hg\n 08:03 PM\n pH (arterial)\n 7.40 units\n 03:30 AM\n pH (venous)\n 7.34 units\n 08:03 PM\n pH (urine)\n 5.0 units\n 10:11 PM\n CO2 (Calc) arterial\n 29 mEq/L\n 03:30 AM\n CO2 (Calc) venous\n 28 mEq/L\n 08:03 PM\n Albumin\n 3.9 g/dL\n 07:58 PM\n Calcium non-ionized\n 8.8 mg/dL\n 03:29 AM\n Phosphorus\n 4.2 mg/dL\n 03:29 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:30 AM\n Magnesium\n 2.7 mg/dL\n 03:29 AM\n ALT\n 19 IU/L\n 07:58 PM\n Alkaline Phosphate\n 66 IU/L\n 07:58 PM\n AST\n 22 IU/L\n 07:58 PM\n Total Bilirubin\n 0.4 mg/dL\n 07:58 PM\n WBC\n 16.7 K/uL\n 03:29 AM\n Hgb\n 12.1 g/dL\n 03:29 AM\n Hematocrit\n 32.9 %\n 03:29 AM\n Current diet order / nutrition support: NPO\n GI: Abd: soft/+bs\n Skin: intact\n Assessment of Nutritional Status\n Adequately nourished, but at risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: (BEE x or / cal/kg)\n Protein: ( g/kg)\n Fluid:\n Estimation of previous intake: likely Adequate\n Estimation of current intake: Inadequate NPO\n Specifics:\n 36 y/o male presents p/ recent travel to c/ AMS, fevers, and\n seizures-presumed to be encephalitis. Pt is intubated and sedated on\n propofol, providing ~660 kcals/day at current rate. Nutrition\n consulted for TF recommendations. Please note goal will change once pt\n is off propofol.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations:\n BG and lyte management as you are\n Please page c/ ?'s #\n" }, { "category": "Nutrition", "chartdate": "2175-01-20 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 429628, "text": "Subjective\n Pt intubated/sedated-no family available\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 68\n 70 kg\n 23.5\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 70 Kg\n 100%\n Diagnosis: AMS\n PMH : mild asthma, h/o lyme disease in \n Food allergies and intolerances: NKFA\n Pertinent medications: propofol gtt, bowel meds, thiamin, folate, RISS,\n heparin, abx, others noted\n Labs:\n Value\n Date\n Glucose\n 116 mg/dL\n 03:29 AM\n Glucose Finger Stick\n 141\n 10:00 AM\n BUN\n 10 mg/dL\n 03:29 AM\n Creatinine\n 1.7 mg/dL\n 03:29 AM\n Sodium\n 138 mEq/L\n 03:29 AM\n Potassium\n 4.5 mEq/L\n 03:29 AM\n Chloride\n 105 mEq/L\n 03:29 AM\n TCO2\n 26 mEq/L\n 03:29 AM\n PO2 (arterial)\n 238 mm Hg\n 03:30 AM\n PO2 (venous)\n 127 mm Hg\n 08:03 PM\n PCO2 (arterial)\n 45 mm Hg\n 03:30 AM\n PCO2 (venous)\n 49 mm Hg\n 08:03 PM\n pH (arterial)\n 7.40 units\n 03:30 AM\n pH (venous)\n 7.34 units\n 08:03 PM\n pH (urine)\n 5.0 units\n 10:11 PM\n CO2 (Calc) arterial\n 29 mEq/L\n 03:30 AM\n CO2 (Calc) venous\n 28 mEq/L\n 08:03 PM\n Albumin\n 3.9 g/dL\n 07:58 PM\n Calcium non-ionized\n 8.8 mg/dL\n 03:29 AM\n Phosphorus\n 4.2 mg/dL\n 03:29 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:30 AM\n Magnesium\n 2.7 mg/dL\n 03:29 AM\n ALT\n 19 IU/L\n 07:58 PM\n Alkaline Phosphate\n 66 IU/L\n 07:58 PM\n AST\n 22 IU/L\n 07:58 PM\n Total Bilirubin\n 0.4 mg/dL\n 07:58 PM\n WBC\n 16.7 K/uL\n 03:29 AM\n Hgb\n 12.1 g/dL\n 03:29 AM\n Hematocrit\n 32.9 %\n 03:29 AM\n Current diet order / nutrition support: NPO\n GI: Abd: soft/+bs\n Skin: intact\n Assessment of Nutritional Status\n Adequately nourished, but at risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1750-2100 (25-30cal/kg)\n Protein: 70-98 (1-1.4 g/kg)\n Fluid: per team\n Estimation of previous intake: likely Adequate\n Estimation of current intake: Inadequate NPO\n Specifics:\n 36 y/o male presents p/ recent travel to c/ AMS, fevers, and\n seizures-presumed to be encephalitis. Pt is intubated and sedated on\n propofol, providing ~660 kcals/day at current rate. Nutrition\n consulted for TF recommendations. Please note goal will change once pt\n is off propofol.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Rec Fibersource @20mL/hr to increase 10mL\n q4 hr to goal of 40mL/hr c/ propofol gtt (1152 kcals/51 gr aa) Once pt\n is off propofol gtt, will need to increase goal rate of TF to 65mL/hr\n (1872 kcals/83 gr aa)\n If pt remains on propofol > 3 days, will need to add beneprotein to TF\n to better meet aa needs. Will make recs if needed\n BG and lyte management as you are\n Please page c/ ?'s #\n" }, { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429633, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, nightsweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he travelled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to Glouchester on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2175-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429634, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, nightsweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he travelled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to Glouchester on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130\n Altered mental status (not Delirium)\n Assessment:\n Rec\nd on 60 of propofol. Pt unresponsive, although withdraws to\n painful stimuli, not following commands. Propofol stopped this am for\n 10minutes\n pt opened eyes briefly, otherwise no change in MS. Pupils\n now Pinpoint b/l and sluggish\nICU team informed.\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 100.8 rectally.\n Action:\n No tyelenol given at this time. Sputum cx was sent last night.\n Ceftriaxone added to broad spectrum antibiotics.\n Response:\n No change.\n Plan:\n Cont to monitor temp curve, tyelenol as needed, f/u on cultures\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd on AC 40%/500x16/5+, LS clear, CXR showing potential haziness to\n LLL. Infrequently sxn\nd for thick tan secretions. Copious white oral\n secretions, Strong cough.\n Action:\n Given MDIs.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2175-01-19 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 429488, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, nightsweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he travelled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to Glouchester on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible ecephalitis. He was persistently\n febrile to 102. At 0500 am , he had a generalized tonic clonic\n seizure lating 45 seconds and desaturated to the low 80s. ABG at that\n time was 7.05/38/60. The patient was then intubated. CXR showed no\n infiltrate.\n Patient admitted from: Transfer from other hospital\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n NKDA\n Infusions:\n Propofol - 60 mcg/Kg/min\n Home medications:\n amoxicillin 500 mg TID\n albuterol inhaler\n Medications on transfer:\n ativan 1 mg po Q6H prn\n ativan 1-2 mg IV/IM Q6H prn seizure\n tylenol prn\n ceftriaxone 2 grams IV daily\n acyclovir 900 mg IV Q8H\n protonix 40 mg IV daily\n peridex 15 mg \n insulin SS\n Past medical history:\n Family history:\n Social History:\n # mild asthma\n # h/o lyme disease in \n - diagnosd with rash, and \"flu symptoms\"\n - treated with antibiotics with improvement\n MGM with CVA at 83. Uncle with CVA. h/o brain tumors in 2 great aunts.\n Also reported h/o blood clots.\n Occupation:\n Drugs: marijuana\n Tobacco: occasional\n Alcohol: occasional\n Other: Lives in . Family lives in . Recent travel to\n 2 weeks ago. Also recent travel to 1 year ago.\n Reportedly promiscuous while in . Per family and friend, has had\n multiple sexual partners. Only sexually active with women. No h/o\n STDs.\n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Edema, Tachycardia\n Respiratory: No(t) Cough, sore throat\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Heme / Lymph: Lymphadenopathy, R axillary LN\n Neurologic: No(t) Numbness / tingling, No(t) Headache, Seizure\n Psychiatric / Sleep: Agitated, No(t) Suicidal, Delirious, No(t) Daytime\n somnolence\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.5\nC (101.3\n HR: 107 (104 - 108) bpm\n BP: 106/60(71) {100/56(66) - 118/65(77)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 284 mL\n PO:\n TF:\n IVF:\n 284 mL\n Blood products:\n Total out:\n 0 mL\n 850 mL\n Urine:\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -566 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 21 cmH2O\n Plateau: 14 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 7.5 L/min\n Physical Examination\n General Appearance: Well nourished, Diaphoretic, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL, R axillary LN\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender:\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, No(t) Oriented (to): , Movement: Purposeful,\n Sedated, Tone: Normal, Opens eyes to voice. doesn't follow commands.\n PERRL. face symmetric. Withdraws all extremities to painful stimuli,\n R>L. Fatiguable clonus in feet bilat, R>L. plantar downgoing bilat. 2+\n relexes symmetric throughout.\n Labs / Radiology\n 437 K/uL\n 13.5 g/dL\n 140 mg/dL\n 1.7 mg/dL\n 9 mg/dL\n 26 mEq/L\n 102 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 37.0 %\n 20.0 K/uL\n [image002.jpg]\n \n 2:33 A12/11/ 07:58 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.0\n Hct\n 37.0\n Plt\n 437\n Cr\n 1.7\n Glucose\n 140\n Other labs: PT / PTT / INR:15.8/28.6/1.4, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:89.3 %, Lymph:6.2 %, Mono:3.8 %,\n Eos:0.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:8.9 mg/dL, Mg++:2.6 mg/dL, PO4:4.0 mg/dL\n Fluid analysis / Other labs:\n Hospital labs :\n 136|97| 9 /162\n 3.9|24|1.5\\\n alb 4.4, Tbili 0.5, ALT 23, AST 21, AP 77\n 9.2>41.4<390, 63 PMNs, 8 Bands, 24 Lymph\n CSF : tube 1: 6 WBCs, 18RBC, glucose = 73, TP = 47, Gram stain\n pending, 86% lymphocytes; tube 4 0 RBCs, 4 WBCs\n CSF was sent for: crypto antigen, hsv, rpr, Cryptococal ag negative\n tox screen positive for cannaboids. Negative for opiates, cocaine,\n benzos, barbs, amphet\n RPR nonreactive\n influenza A+B: presumptive negative\n U/A: 5 ketones, SG 1.015, pH 6.0, trace blood, LE, nitrite, glu, bili,\n pro negative. 0-2 RBCs. 0-2 WBCs. Rare bacteria. granular casts.\n blood cultures NGTD\n Lyme Ag, CD4, HIV pending\n Hospital labs :\n 8.0>40.1<343, 67% PMNs, 17% lymphs, eos 1%\n 136|101|8 /131\n 4.3|26|1.2\\\n Imaging: From Hospital :\n .\n CT head : no acute intracranial abnormalities\n .\n CXR : no acute pathology\n ECG: ECG : Sinus tach at 103. Nl axis and intervals. Incomplete\n RBBB. NSSTTW changes.\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # fevers: given persistent high fevers, altered mental status,\n seizures, and LP results, suspect aseptic meningioencephalitis. CSF\n studies not c/w bacterial infection. Significant leukocytosis with\n left shift raises concern for bacterial process although could be\n stress response from recent seizure. Ddx of aseptic\n meningioencephalitis includes viral (HSV, enterovirus, HIV, west ,\n VZV, mumps), vasculitis, malignancy. ? exposure to toxin in \n leading to encephalitis. At OSH HIV negative, RPR negative, crypto CSF\n negative.\n - MRI\n - cont empiric acyclovir at 10 mg/kg Q8H\n - cont empiric ceftriaxone. Would add vancomycin to cover possible PCN\n resistent strep and ampicillin to cover listeria although no reason to\n suspect immunocompromised\n - repeat LP in am for cell count, protein, glucose, HSV PCR, HIV, Lyme,\n west PCR, enterovirus PCR\n - stool culture for enteric viruses\n - check HIV Ab, HIV VL, CD4\n - consider serologic testing for cocksackie, echovirus, west , EBV,\n Lyme\n - send blood cultures, U/A, urine culture\n - check CXR\n - sputum and stool cultures prn\n - consider placing PPD\n - droplet precautions\n .\n # respiratory failure: intubated in the setting of seizure with\n metabolic acidosis. CXR without significant pulmonary pathology.\n - RSBI, SBT qam\n - albuterol/atrovent nebs\n .\n # seizures: possibly due to irritable focus from infection or anatomic\n abnormality. EtOH history unclear so must also consider EtOH withdrawal\n seizures although seems less likely in current setting. Discussed with\n Neuro. In setting of acute illness and single isolated seizure, no need\n for prophylaxis.\n - check MRI\n - folate/thiamine\n - propofol drip for sedation with have some effect on EtoH withdrawal\n ppx\n - ativan prn for seizures\n .\n # altered mental status: given high fevers, altered mental status, and\n results of LP, suspect encephalitis. At OSH had no other evidence of\n infection. Tox + for cannaboids but unlikely to cause persistent\n altered MS. Could have used other illicit drugs in although\n was 2 weeks ago so doubt persistent effects. Could also be subclinical\n seizures. Also toxic metabolic encephalopathy.\n - fever treatment as above\n - Neuro consult in am\n - renal failure treatment as below\n .\n # ARF: At OSH, initial Cr 1.5 and improved this am to 1.2. Now again\n elevated to 1.7. Presumably had normal renal function prior. Initial\n ARF likely due to dehydration due to poor po intake and increased\n insensible losses from fevers. Now suspect new process. ? contribution\n of acyclovir.\n - aggressive IVF\n - urine lytes\n - urine eos\n - trend Cr\n .\n # sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration.\n - IVF as above\n - tylenol prn for fevers\n - ID treatment as above\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: NPO for now\n - nutrition recs for ? TFs as may have prolonged intubation\n .\n # PPx: heparin sc. PPI while on vent. bowel regimen\n .\n # ACCESS: PIV x 3\n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: ICU\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2175-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429969, "text": "History: Mr. is a 36 year old healthy male with recent travel\n to who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Pt was extubated on . remains on RA with sat 98-100%, no c/o of\n sob.\n Altered mental status (not Delirium)\n Assessment:\n Pt is A + O x 2, can state name and place, confused to time. . PERRL,\n MAEs normal strength, follows commands consistently but needs freq\n redirection. Cannot understand how to use call light. Pt\n intermittently pulling ECG leads, BP cuff despite explanation.\n Action:\n Bed low, locked, alarm on. Freq neuro checks, reorientation. PIV\n replaced (covered w/ arm ), pt voiding w/ urinal in bed.\n Response:\n Pt is free from falls. Head MRI found no evidence of abnormality.\n Plan:\n Freq asses MS, cont to tx for infection, and cx\ns. please sent throat\n viral culture awaiting special tube M4 Media\n" }, { "category": "Physician ", "chartdate": "2175-01-20 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 429490, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, nightsweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he travelled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to Glouchester on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible ecephalitis. He was persistently\n febrile to 102. At 0500 am , he had a generalized tonic clonic\n seizure lating 45 seconds and desaturated to the low 80s. ABG at that\n time was 7.05/38/60. The patient was then intubated. CXR showed no\n infiltrate.\n Patient admitted from: Transfer from other hospital\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n NKDA\n Infusions:\n Propofol - 60 mcg/Kg/min\n Home medications:\n amoxicillin 500 mg TID\n albuterol inhaler\n Medications on transfer:\n ativan 1 mg po Q6H prn\n ativan 1-2 mg IV/IM Q6H prn seizure\n tylenol prn\n ceftriaxone 2 grams IV daily\n acyclovir 900 mg IV Q8H\n protonix 40 mg IV daily\n peridex 15 mg \n insulin SS\n Past medical history:\n Family history:\n Social History:\n # mild asthma\n # h/o lyme disease in \n - diagnosd with rash, and \"flu symptoms\"\n - treated with antibiotics with improvement\n MGM with CVA at 83. Uncle with CVA. h/o brain tumors in 2 great aunts.\n Also reported h/o blood clots.\n Occupation:\n Drugs: marijuana\n Tobacco: occasional\n Alcohol: occasional\n Other: Lives in . Family lives in . Recent travel to\n 2 weeks ago. Also recent travel to 1 year ago.\n Reportedly promiscuous while in . Per family and friend, has had\n multiple sexual partners. Only sexually active with women. No h/o\n STDs.\n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Edema, Tachycardia\n Respiratory: No(t) Cough, sore throat\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Heme / Lymph: Lymphadenopathy, R axillary LN\n Neurologic: No(t) Numbness / tingling, No(t) Headache, Seizure\n Psychiatric / Sleep: Agitated, No(t) Suicidal, Delirious, No(t) Daytime\n somnolence\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.5\nC (101.3\n HR: 107 (104 - 108) bpm\n BP: 106/60(71) {100/56(66) - 118/65(77)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 284 mL\n PO:\n TF:\n IVF:\n 284 mL\n Blood products:\n Total out:\n 0 mL\n 850 mL\n Urine:\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -566 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 21 cmH2O\n Plateau: 14 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 7.5 L/min\n Physical Examination\n General Appearance: Well nourished, Diaphoretic, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL, R axillary LN\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender:\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, No(t) Oriented (to): , Movement: Purposeful,\n Sedated, Tone: Normal, Opens eyes to voice. doesn't follow commands.\n PERRL. face symmetric. Withdraws all extremities to painful stimuli,\n R>L. Fatiguable clonus in feet bilat, R>L. plantar downgoing bilat. 2+\n relexes symmetric throughout.\n Labs / Radiology\n 437 K/uL\n 13.5 g/dL\n 140 mg/dL\n 1.7 mg/dL\n 9 mg/dL\n 26 mEq/L\n 102 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 37.0 %\n 20.0 K/uL\n [image002.jpg]\n \n 2:33 A12/11/ 07:58 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.0\n Hct\n 37.0\n Plt\n 437\n Cr\n 1.7\n Glucose\n 140\n Other labs: PT / PTT / INR:15.8/28.6/1.4, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:89.3 %, Lymph:6.2 %, Mono:3.8 %,\n Eos:0.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:8.9 mg/dL, Mg++:2.6 mg/dL, PO4:4.0 mg/dL\n Fluid analysis / Other labs:\n Hospital labs :\n 136|97| 9 /162\n 3.9|24|1.5\\\n alb 4.4, Tbili 0.5, ALT 23, AST 21, AP 77\n 9.2>41.4<390, 63 PMNs, 8 Bands, 24 Lymph\n CSF : tube 1: 6 WBCs, 18RBC, glucose = 73, TP = 47, Gram stain\n pending, 86% lymphocytes; tube 4 0 RBCs, 4 WBCs\n CSF was sent for: crypto antigen, hsv, rpr, Cryptococal ag negative\n tox screen positive for cannaboids. Negative for opiates, cocaine,\n benzos, barbs, amphet\n RPR nonreactive\n influenza A+B: presumptive negative\n U/A: 5 ketones, SG 1.015, pH 6.0, trace blood, LE, nitrite, glu, bili,\n pro negative. 0-2 RBCs. 0-2 WBCs. Rare bacteria. granular casts.\n blood cultures NGTD\n Lyme Ag, CD4, HIV pending\n Hospital labs :\n 8.0>40.1<343, 67% PMNs, 17% lymphs, eos 1%\n 136|101|8 /131\n 4.3|26|1.2\\\n Imaging: From Hospital :\n .\n CT head : no acute intracranial abnormalities\n .\n CXR : no acute pathology\n ECG: ECG : Sinus tach at 103. Nl axis and intervals. Incomplete\n RBBB. NSSTTW changes.\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # fevers: given persistent high fevers, altered mental status,\n seizures, and LP results, suspect aseptic meningioencephalitis. CSF\n studies not c/w bacterial infection. Significant leukocytosis with\n left shift raises concern for bacterial process although could be\n stress response from recent seizure. Ddx of aseptic\n meningioencephalitis includes viral (HSV, enterovirus, HIV, west ,\n VZV, mumps), vasculitis, malignancy. ? exposure to toxin in \n leading to encephalitis. At OSH HIV negative, RPR negative, crypto CSF\n negative.\n - MRI\n - cont empiric acyclovir at 10 mg/kg Q8H\n - cont empiric ceftriaxone. Would add vancomycin to cover possible PCN\n resistent strep and ampicillin to cover listeria although no reason to\n suspect immunocompromised\n - repeat LP in am for cell count, protein, glucose, HSV PCR, HIV, Lyme,\n west PCR, enterovirus PCR\n - stool culture for enteric viruses\n - check HIV Ab, HIV VL, CD4\n - consider serologic testing for cocksackie, echovirus, west , EBV,\n Lyme\n - send blood cultures, U/A, urine culture\n - check CXR\n - sputum and stool cultures prn\n - consider placing PPD\n - droplet precautions\n .\n # respiratory failure: intubated in the setting of seizure with\n metabolic acidosis. CXR without significant pulmonary pathology.\n - RSBI, SBT qam\n - albuterol/atrovent nebs\n .\n # seizures: possibly due to irritable focus from infection or anatomic\n abnormality. EtOH history unclear so must also consider EtOH withdrawal\n seizures although seems less likely in current setting. Discussed with\n Neuro. In setting of acute illness and single isolated seizure, no need\n for prophylaxis.\n - check MRI\n - folate/thiamine\n - propofol drip for sedation with have some effect on EtoH withdrawal\n ppx\n - ativan prn for seizures\n .\n # altered mental status: given high fevers, altered mental status, and\n results of LP, suspect encephalitis. At OSH had no other evidence of\n infection. Tox + for cannaboids but unlikely to cause persistent\n altered MS. Could have used other illicit drugs in although\n was 2 weeks ago so doubt persistent effects. Could also be subclinical\n seizures. Also toxic metabolic encephalopathy.\n - fever treatment as above\n - Neuro consult in am\n - renal failure treatment as below\n .\n # ARF: At OSH, initial Cr 1.5 and improved this am to 1.2. Now again\n elevated to 1.7. Presumably had normal renal function prior. Initial\n ARF likely due to dehydration due to poor po intake and increased\n insensible losses from fevers. Now suspect new process. ? contribution\n of acyclovir.\n - aggressive IVF\n - urine lytes\n - urine eos\n - trend Cr\n .\n # sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration.\n - IVF as above\n - tylenol prn for fevers\n - ID treatment as above\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: NPO for now\n - nutrition recs for ? TFs as may have prolonged intubation\n .\n # PPx: heparin sc. PPI while on vent. bowel regimen\n .\n # ACCESS: PIV x 3\n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: ICU\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 36 M who was in in late admitted with fevers, sore\n throat and worsening delirium. In the ER, he was febrile, had a\n bandemia and negative head CT. His LP showed a WBC count of 6 and 4 and\n RBC count of 18 and 0 in tube 1 and 4. His TP was 47 and glucose normal\n at 73. He had a generalized seizure and was intubated with a metabolic\n acidosis causing a pH of 7.03.\n He has been treated thus far with acyclovir, ceftriaxone, vancomycin,\n and ampicillin. He is currently stable on the vent and receiving\n propofol for sedation. He has occasional myoclonic jerks.\n Exam notable for Tm 101.3 HR 114 BP 103/63 RR with 99 sat on AC\n 16/500/5/.5\n Sedated, intubated, unresponsive, occasional myclonic jerks of upper\n extremities\n Perrl\n Neck supple\n Hrt tachy, regular\n Lung clear\n Abd benign\n Extrem\n no edema\n Outside head Ct apparently unremarkable\n MRI pending\n Labs notable for WBC 20 K, HCT 37 , Na 138 ,K+ 4.7 , HCO3 26 ,Cr 1.7\n ,lactate 1.6\n Imaging: CXR clear, ETT and OG OK\n Problems: likely viral encephalitis, seizure, renal dysfunction,\n respiratory failure\n Agree with plan to await pending LP results and repeat LP for further\n studies, MRI, continue broad antibiotics including acyclovir, IV\n hydration and follow creatinine closely, follow for signs of seizure,\n consider lightening sedation and SBT in AM\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 38 min\n ------ Protected Section Addendum Entered By: , MD\n on: 00:53 ------\n" }, { "category": "Physician ", "chartdate": "2175-01-20 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 429491, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, nightsweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he travelled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to Glouchester on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible ecephalitis. He was persistently\n febrile to 102. At 0500 am , he had a generalized tonic clonic\n seizure lating 45 seconds and desaturated to the low 80s. ABG at that\n time was 7.05/38/60. The patient was then intubated. CXR showed no\n infiltrate.\n Patient admitted from: Transfer from other hospital\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n NKDA\n Infusions:\n Propofol - 60 mcg/Kg/min\n Home medications:\n amoxicillin 500 mg TID\n albuterol inhaler\n Medications on transfer:\n ativan 1 mg po Q6H prn\n ativan 1-2 mg IV/IM Q6H prn seizure\n tylenol prn\n ceftriaxone 2 grams IV daily\n acyclovir 900 mg IV Q8H\n protonix 40 mg IV daily\n peridex 15 mg \n insulin SS\n Past medical history:\n Family history:\n Social History:\n # mild asthma\n # h/o lyme disease in \n - diagnosd with rash, and \"flu symptoms\"\n - treated with antibiotics with improvement\n MGM with CVA at 83. Uncle with CVA. h/o brain tumors in 2 great aunts.\n Also reported h/o blood clots.\n Occupation:\n Drugs: marijuana\n Tobacco: occasional\n Alcohol: occasional\n Other: Lives in . Family lives in . Recent travel to\n 2 weeks ago. Also recent travel to 1 year ago.\n Reportedly promiscuous while in . Per family and friend, has had\n multiple sexual partners. Only sexually active with women. No h/o\n STDs.\n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Edema, Tachycardia\n Respiratory: No(t) Cough, sore throat\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Heme / Lymph: Lymphadenopathy, R axillary LN\n Neurologic: No(t) Numbness / tingling, No(t) Headache, Seizure\n Psychiatric / Sleep: Agitated, No(t) Suicidal, Delirious, No(t) Daytime\n somnolence\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:09 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.5\nC (101.3\n HR: 107 (104 - 108) bpm\n BP: 106/60(71) {100/56(66) - 118/65(77)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 284 mL\n PO:\n TF:\n IVF:\n 284 mL\n Blood products:\n Total out:\n 0 mL\n 850 mL\n Urine:\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -566 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 21 cmH2O\n Plateau: 14 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 7.5 L/min\n Physical Examination\n General Appearance: Well nourished, Diaphoretic, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL, R axillary LN\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender:\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, No(t) Oriented (to): , Movement: Purposeful,\n Sedated, Tone: Normal, Opens eyes to voice. doesn't follow commands.\n PERRL. face symmetric. Withdraws all extremities to painful stimuli,\n R>L. Fatiguable clonus in feet bilat, R>L. plantar downgoing bilat. 2+\n relexes symmetric throughout.\n Labs / Radiology\n 437 K/uL\n 13.5 g/dL\n 140 mg/dL\n 1.7 mg/dL\n 9 mg/dL\n 26 mEq/L\n 102 mEq/L\n 4.7 mEq/L\n 138 mEq/L\n 37.0 %\n 20.0 K/uL\n [image002.jpg]\n \n 2:33 A12/11/ 07:58 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.0\n Hct\n 37.0\n Plt\n 437\n Cr\n 1.7\n Glucose\n 140\n Other labs: PT / PTT / INR:15.8/28.6/1.4, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:89.3 %, Lymph:6.2 %, Mono:3.8 %,\n Eos:0.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:8.9 mg/dL, Mg++:2.6 mg/dL, PO4:4.0 mg/dL\n Fluid analysis / Other labs:\n Hospital labs :\n 136|97| 9 /162\n 3.9|24|1.5\\\n alb 4.4, Tbili 0.5, ALT 23, AST 21, AP 77\n 9.2>41.4<390, 63 PMNs, 8 Bands, 24 Lymph\n CSF : tube 1: 6 WBCs, 18RBC, glucose = 73, TP = 47, Gram stain\n pending, 86% lymphocytes; tube 4 0 RBCs, 4 WBCs\n CSF was sent for: crypto antigen, hsv, rpr, Cryptococal ag negative\n tox screen positive for cannaboids. Negative for opiates, cocaine,\n benzos, barbs, amphet\n RPR nonreactive\n influenza A+B: presumptive negative\n U/A: 5 ketones, SG 1.015, pH 6.0, trace blood, LE, nitrite, glu, bili,\n pro negative. 0-2 RBCs. 0-2 WBCs. Rare bacteria. granular casts.\n blood cultures NGTD\n Lyme Ag, CD4, HIV pending\n Hospital labs :\n 8.0>40.1<343, 67% PMNs, 17% lymphs, eos 1%\n 136|101|8 /131\n 4.3|26|1.2\\\n Imaging: From Hospital :\n .\n CT head : no acute intracranial abnormalities\n .\n CXR : no acute pathology\n ECG: ECG : Sinus tach at 103. Nl axis and intervals. Incomplete\n RBBB. NSSTTW changes.\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # fevers: given persistent high fevers, altered mental status,\n seizures, and LP results, suspect aseptic meningioencephalitis. CSF\n studies not c/w bacterial infection. Significant leukocytosis with\n left shift raises concern for bacterial process although could be\n stress response from recent seizure. Ddx of aseptic\n meningioencephalitis includes viral (HSV, enterovirus, HIV, west ,\n VZV, mumps), vasculitis, malignancy. ? exposure to toxin in \n leading to encephalitis. At OSH HIV negative, RPR negative, crypto CSF\n negative.\n - MRI\n - cont empiric acyclovir at 10 mg/kg Q8H\n - cont empiric ceftriaxone. Would add vancomycin to cover possible PCN\n resistent strep and ampicillin to cover listeria although no reason to\n suspect immunocompromised\n - repeat LP in am for cell count, protein, glucose, HSV PCR, HIV, Lyme,\n west PCR, enterovirus PCR\n - stool culture for enteric viruses\n - check HIV Ab, HIV VL, CD4\n - consider serologic testing for cocksackie, echovirus, west , EBV,\n Lyme\n - send blood cultures, U/A, urine culture\n - check CXR\n - sputum and stool cultures prn\n - consider placing PPD\n - droplet precautions\n .\n # respiratory failure: intubated in the setting of seizure with\n metabolic acidosis. CXR without significant pulmonary pathology.\n - RSBI, SBT qam\n - albuterol/atrovent nebs\n .\n # seizures: possibly due to irritable focus from infection or anatomic\n abnormality. EtOH history unclear so must also consider EtOH withdrawal\n seizures although seems less likely in current setting. Discussed with\n Neuro. In setting of acute illness and single isolated seizure, no need\n for prophylaxis.\n - check MRI\n - folate/thiamine\n - propofol drip for sedation with have some effect on EtoH withdrawal\n ppx\n - ativan prn for seizures\n .\n # altered mental status: given high fevers, altered mental status, and\n results of LP, suspect encephalitis. At OSH had no other evidence of\n infection. Tox + for cannaboids but unlikely to cause persistent\n altered MS. Could have used other illicit drugs in although\n was 2 weeks ago so doubt persistent effects. Could also be subclinical\n seizures. Also toxic metabolic encephalopathy.\n - fever treatment as above\n - Neuro consult in am\n - renal failure treatment as below\n .\n # ARF: At OSH, initial Cr 1.5 and improved this am to 1.2. Now again\n elevated to 1.7. Presumably had normal renal function prior. Initial\n ARF likely due to dehydration due to poor po intake and increased\n insensible losses from fevers. Now suspect new process. ? contribution\n of acyclovir.\n - aggressive IVF\n - urine lytes\n - urine eos\n - trend Cr\n .\n # sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration.\n - IVF as above\n - tylenol prn for fevers\n - ID treatment as above\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: NPO for now\n - nutrition recs for ? TFs as may have prolonged intubation\n .\n # PPx: heparin sc. PPI while on vent. bowel regimen\n .\n # ACCESS: PIV x 3\n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: ICU\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 36 M who was in in late admitted with fevers, sore\n throat and worsening delirium. In the ER, he was febrile, had a\n bandemia and negative head CT. His LP showed a WBC count of 6 and 4 and\n RBC count of 18 and 0 in tube 1 and 4. His TP was 47 and glucose normal\n at 73. He had a generalized seizure and was intubated with a metabolic\n acidosis causing a pH of 7.03.\n He has been treated thus far with acyclovir, ceftriaxone, vancomycin,\n and ampicillin. He is currently stable on the vent and receiving\n propofol for sedation. He has occasional myoclonic jerks.\n Exam notable for Tm 101.3 HR 114 BP 103/63 RR with 99 sat on AC\n 16/500/5/.5\n Sedated, intubated, unresponsive, occasional myclonic jerks of upper\n extremities\n Perrl\n Neck supple\n Hrt tachy, regular\n Lung clear\n Abd benign\n Extrem\n no edema\n Outside head Ct apparently unremarkable\n MRI pending\n Labs notable for WBC 20 K, HCT 37 , Na 138 ,K+ 4.7 , HCO3 26 ,Cr 1.7\n ,lactate 1.6\n Imaging: CXR clear, ETT and OG OK\n Problems: likely viral encephalitis, seizure, renal dysfunction,\n respiratory failure\n Agree with plan to await pending LP results and repeat LP for further\n studies, MRI, continue broad antibiotics including acyclovir, IV\n hydration and follow creatinine closely, follow for signs of seizure,\n consider lightening sedation and SBT in AM\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 38 min\n ------ Protected Section Addendum Entered By: , MD\n on: 00:53 ------\n ------ Protected Section Addendum Entered By: , MD\n on: 00:57 ------\n" }, { "category": "Physician ", "chartdate": "2175-01-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429603, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:39 PM\n start time is approximate\n BLOOD CULTURED - At 08:00 PM\n PAN CULTURE - At 10:30 PM\n EKG - At 10:49 PM\n ARTERIAL LINE - START 12:28 AM\n FEVER - 101.3\nF - 07:47 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 11:08 PM\n Vancomycin - 12:09 AM\n Ampicillin - 12:09 AM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.5\nC (99.5\n HR: 97 (97 - 112) bpm\n BP: 106/61(75) {100/61(75) - 113/67(80)} mmHg\n RR: 16 (16 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 389 mL\n 1,865 mL\n PO:\n TF:\n IVF:\n 389 mL\n 1,865 mL\n Blood products:\n Total out:\n 910 mL\n 520 mL\n Urine:\n 910 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -521 mL\n 1,345 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 22 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 99%\n ABG: 7.40/45/238/26/2\n Ve: 7.3 L/min\n PaO2 / FiO2: 476\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 379 K/uL\n 12.1 g/dL\n 116 mg/dL\n 1.7 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 10 mg/dL\n 105 mEq/L\n 138 mEq/L\n 32.9 %\n 16.7 K/uL\n [image002.jpg]\n 07:58 PM\n 03:29 AM\n 03:30 AM\n WBC\n 20.0\n 16.7\n Hct\n 37.0\n 32.9\n Plt\n 437\n 379\n Cr\n 1.7\n 1.7\n TCO2\n 29\n Glucose\n 140\n 116\n Other labs: PT / PTT / INR:15.8/28.6/1.4, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:89.3 %, Lymph:6.2 %, Mono:3.8 %,\n Eos:0.7 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # fevers: given persistent high fevers, altered mental status,\n seizures, and LP results, suspect aseptic meningioencephalitis. CSF\n studies not c/w bacterial infection. Significant leukocytosis with\n left shift raises concern for bacterial process although could be\n stress response from recent seizure. Ddx of aseptic\n meningioencephalitis includes viral (HSV, enterovirus, HIV, west ,\n VZV, mumps), vasculitis, malignancy. ? exposure to toxin in \n leading to encephalitis. At OSH HIV negative, RPR negative, crypto CSF\n negative.\n - MRI\n - cont empiric acyclovir at 10 mg/kg Q8H\n - cont empiric ceftriaxone. Would add vancomycin to cover possible PCN\n resistent strep and ampicillin to cover listeria although no reason to\n suspect immunocompromised\n - repeat LP in am for cell count, protein, glucose, HSV PCR, HIV, Lyme,\n west PCR, enterovirus PCR\n - stool culture for enteric viruses\n - check HIV Ab, HIV VL, CD4\n - consider serologic testing for cocksackie, echovirus, west , EBV,\n Lyme\n - send blood cultures, U/A, urine culture\n - check CXR\n - sputum and stool cultures prn\n - consider placing PPD\n - droplet precautions\n .\n # respiratory failure: intubated in the setting of seizure with\n metabolic acidosis. CXR without significant pulmonary pathology.\n - RSBI, SBT qam\n - albuterol/atrovent nebs\n .\n # seizures: possibly due to irritable focus from infection or anatomic\n abnormality. EtOH history unclear so must also consider EtOH withdrawal\n seizures although seems less likely in current setting. Discussed with\n Neuro. In setting of acute illness and single isolated seizure, no need\n for prophylaxis.\n - check MRI\n - folate/thiamine\n - propofol drip for sedation with have some effect on EtoH withdrawal\n ppx\n - ativan prn for seizures\n .\n # altered mental status: given high fevers, altered mental status, and\n results of LP, suspect encephalitis. At OSH had no other evidence of\n infection. Tox + for cannaboids but unlikely to cause persistent\n altered MS. Could have used other illicit drugs in although\n was 2 weeks ago so doubt persistent effects. Could also be subclinical\n seizures. Also toxic metabolic encephalopathy.\n - fever treatment as above\n - Neuro consult in am\n - renal failure treatment as below\n .\n # ARF: At OSH, initial Cr 1.5 and improved this am to 1.2. Now again\n elevated to 1.7. Presumably had normal renal function prior. Initial\n ARF likely due to dehydration due to poor po intake and increased\n insensible losses from fevers. Now suspect new process. ? contribution\n of acyclovir.\n - aggressive IVF\n - urine lytes\n - urine eos\n - trend Cr\n .\n # sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration.\n - IVF as above\n - tylenol prn for fevers\n - ID treatment as above\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: NPO for now\n - nutrition recs for ? TFs as may have prolonged intubation\n .\n # PPx: heparin sc. PPI while on vent. bowel regimen\n .\n # ACCESS: PIV x 3\n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: ICU\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:40 PM\n 18 Gauge - 08:00 PM\n Arterial Line - 12:28 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2175-01-20 00:00:00.000", "description": "ICU Event Note", "row_id": 429580, "text": "Clinician: Attending\n Critical Care\n Remains febrile with elevated WBC. Unclear if the change in WBC from\n OSH is due to CNS process or due to possible aspiration and developing\n pneumonia. Will stop propofol after MR today and assess whether\n he needs to remain intubated - secretions may preclude extubation for a\n time. Neuro reqs in and ID will see today. Likely viral encephalitis\n but will continue abx pending cx from OSH. He is at signif risk for\n HIV which broadens differential.\n Total time spent: 45 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2175-01-21 00:00:00.000", "description": "MICU staff progress note", "row_id": 429847, "text": "TITLE: MICU ATTENDING Progress note\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note from today, including the assessment and plan. I would\n emphasize and add the following points: 36 year old male without\n significant past medical history presented initially to OSH ,\n transferred to on with fevers, altered mental status,\n seizures and respiratory failure. W/u appears most c/w viral\n encephalopathy, though CNS bacterial cx data remains pending and\n initially also concern for possible pna given secretions. ID and neuro\n following. Remains on bacterial meningitis coverage and acyclovir. Cx\n data, HSV PCR, and viral w/u pending. EEG with evidence of\n toxic/metabolic encephalopathy. MRI overnight. Extubated successfully\n pre-rounds this am.\n EXAM: TM 100.8\nAF 128/82 HR 92 RR 23 98% RA I/O's 8900/3100 +\n 5700, -300 since MN, WDWN M, alert, oriented to self and place, remains\n slow to respond, confused, no JVD, CTA with scant basilar rales R > L,\n RR, benign abd, no edema, nonfocal neuro\n LABS: WBC 8.9 (16.7) Hct 31.3, inr 1.3 K 4.1 cr 1.1 (1.4) na 142\n HIV viral load neg\n CSF--crypto pending, HSV PCR pending\n bacterial cx pending\n blood cx pending\n MRI-pending\n CXR: no evidence of focal process\n Fever curve has improved now af with decreasing wbc. There appears no\n evidence of pna on cxr. Will continue current cns coverage and discuss\n with antibx and acyclovir pending cx data. F/u viral work-up and ID\n recs. Improving from mental status standpoint but remains confused.\n Continue to monitor and reorient. F/u MRI results and neuro recs,\n continuing keppra for szs. ARF improving with hydration. Stable from\n respiratory standpoiunt post extubation. Can slowly advance diet with\n supervision. Remains with mild sinus tach\nfollow and check tsh.\n Monitor in ICU tonight, anticipate transfer to floor with sitter in am.\n Time spent: 45 min\n" }, { "category": "Physician ", "chartdate": "2175-01-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429910, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 02:00 PM\n LUMBAR PUNCTURE - At 04:30 PM\n CSF CULTURE - At 05:00 PM\n ARTERIAL LINE - STOP 05:50 PM\n MAGNETIC RESONANCE IMAGING - At 01:03 AM\n .\n -secretions remain high overnight\n -extubated in AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 10:00 AM\n Acyclovir - 10:00 PM\n Vancomycin - 10:15 PM\n Ampicillin - 12:33 AM\n Infusions:\n Propofol - 80 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.4\nC (97.5\n HR: 86 (78 - 100) bpm\n BP: 128/82(91) {112/62(74) - 141/85(96)} mmHg\n RR: 9 (9 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 8,913 mL\n 317 mL\n PO:\n TF:\n IVF:\n 8,703 mL\n 317 mL\n Blood products:\n Total out:\n 3,192 mL\n 650 mL\n Urine:\n 3,192 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,721 mL\n -333 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 100%\n ABG: ///28/\n Ve: 8 L/min\n Physical Examination\n General Appearance: intubatedextubated, awake\n Eyes / Conjunctiva: PERRL, anicteric\n Head, Ears, Nose, Throat: Normocephalic, ET/OG tubes in place\n Lymphatic: Cervical WNL, Supraclavicular WNL, R axillary LN approx 1cm\n in size\n Cardiovascular: RRR S1S2 no m/r/g\n Peripheral Vascular: warm, well perfused 2+dp pulses\n Respiratory / Chest: clear bilaterally while supine. Notable is mild\n swelling in L chest (breast) no erythema.\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: no cyanosis, no edema, no rashes\n Neurologic: AOX1, unaware of place or time, CNs intact\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 10.9 g/dL\n 103 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 108 mEq/L\n 142 mEq/L\n 31.3 %\n 8.9 K/uL\n [image002.jpg]\n 07:58 PM\n 03:29 AM\n 03:30 AM\n 03:58 PM\n 04:13 AM\n WBC\n 20.0\n 16.7\n 8.9\n Hct\n 37.0\n 32.9\n 31.3\n Plt\n 437\n 379\n 306\n Cr\n 1.7\n 1.7\n 1.4\n 1.1\n TCO2\n 29\n Glucose\n 140\n 116\n 122\n 103\n Other labs: PT / PTT / INR:14.7/30.3/1.3, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:79.9 %, Lymph:15.2 %, Mono:3.2 %,\n Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # Fevers: Persistently high fevers in setting of myalgias, sore throat\n raises suspicion for viral prodrome and infection. Altered mental\n status and seizure x1 also causes concern for meningitis vs.\n encephalitis. The patient had LP at OSH but per neuro service would be\n useful to tap again and run for various viral serologies and infectious\n labs. CSF at OSH not consistent with bacterial infection. CXR appears\n clear w/question of haziness in LLL. Clinically lungs are clear on exam\n but noted this AM was increased sputum production, and sample was sent\n for culture. Given patient\ns history he is at increased risk for HIV\n (study pending at OSH). In addition to infectious causes (including\n HIV, EBV, HSV, Cryptococcus, etc) etiologies such as vasculitis and\n malignancy should be considered.\n - MRI/MRA to further work up anatomy and ? vasculitis\n - cont acyclovir, vancomycin, ampicillin, ceftriaxone for infectious\n etiology\n - repeat LP in am for cell count, protein, glucose, HSV PCR, HIV, Lyme,\n west PCR, enterovirus PCR\n - f/u stool cultures\n - f/u HIV labs\n -f/u ID and neurology recommendations\n continue current mgmt, cont\n acyclovir, d/c remainder of abx, keep keppra\n - f/u blood cultures, urine culture and sputum cultures\n .\n # Respiratory failure: intubated in the setting of seizure with\n metabolic acidosis. CXR without significant pulmonary pathology\n although increasing sputum production.\n - RSBI, SBT qam\n - albuterol/atrovent nebs\n -if increasing secretions would hold off on extubation\n - extubated - resolved\n .\n # Seizures: Consider toxic-metabolic vs infectious etiology vs.\n structural abdormality of focus. Ct negative at outside hospital. MRI\n to be done today. Per neurology will start keppra and monitor for\n seizure activity with EEG.\n - check MRI - normal MRI/MRA\n - keppra\n - propofol drip for sedation\n d/c\n - ativan prn for seizures\n -monitor and replete electrolytes\n -tox screen negative except for marijuana\n .\n # Altered mental status: given high fevers, altered mental status, and\n results of LP, suspect encephalitis. At OSH had no other evidence of\n infection. Tox + for cannaboids but unlikely to cause persistent\n altered MS. Also noted by family was change in behavior from his\n baseline since his return from overseas. Will continue to work up for\n toxic/metabolic and infectious etiologies.\n - fever treatment as above\n - f/u neuro consult\n keep keppra\n f/u s/p MRI/MRA results\n - renal failure treatment as below\n .\n # ARF: At OSH, initial Cr 1.5 and improved this am to 1.2. Now again\n elevated to 1.7. Presumably had normal renal function prior. Initial\n ARF likely due to dehydration due to poor po intake and increased\n insensible losses from fevers. Also suspect acyclovir may have caused\n intrinsic renal damage.\n - aggressive IVF\n - renally dose meds\n - trend Cr\n -spin urine if ? acyclovir damage\n .\n # Sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration. Much better this morning.\n - IVF as above\n - monitor fever curve\n - ID treatment as above\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: changed to clears, ADAT now, replete electrolytes prn, nutrition\n recs if prolonged intubation.\n -monitor INR (1.5), may need vitamin K if concern for bleed\n .\n # PPx: heparin sc. PPI while on vent. bowel regimen\n .\n # ACCESS: PIV x 3, aline\n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: ICU\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 07:40 PM\n 18 Gauge - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2175-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429912, "text": "Mr. is a 36 year old healthy male with recent travel to\n who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2175-01-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429996, "text": "Chief Complaint:\n 24 Hour Events:\n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 10:00 AM\n Pt attempted to get out of bed and pulled on foley catheter. This RN\n removed foley b/c pt c/o bladder spasm/pain.\n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 12:00 PM\n Pt pulled out PIV\n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 05:00 PM\n Pt pulled out PIV, replaced w/20 gauge\n - extubated in AM\n - MRI/MRA - normal\n - remains on Acyclovir, d/c'd other antibitoics\n - ID recs - cont Acyclovir, awaiting MRI\n - Neuro - continue Keppra, defer to ID\n - ADAT\n - no issues overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 06:26 AM\n Vancomycin - 08:30 AM\n Ceftriaxone - 10:30 AM\n Acyclovir - 10:16 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 07:40 PM\n Heparin Sodium (Prophylaxis) - 10:17 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 36.3\nC (97.4\n HR: 86 (70 - 103) bpm\n BP: 137/86(98) {124/41(25) - 159/101(107)} mmHg\n RR: 28 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,384 mL\n 563 mL\n PO:\n 500 mL\n TF:\n IVF:\n 2,884 mL\n 563 mL\n Blood products:\n Total out:\n 3,810 mL\n 550 mL\n Urine:\n 3,810 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -426 mL\n 13 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 198 (198 - 198) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n FiO2: 40%\n SpO2: 96%\n ABG: ///31/\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 395 K/uL\n 12.4 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 6 mg/dL\n 104 mEq/L\n 141 mEq/L\n 35.2 %\n 8.1 K/uL\n [image002.jpg]\n 07:58 PM\n 03:29 AM\n 03:30 AM\n 03:58 PM\n 04:13 AM\n 04:26 AM\n WBC\n 20.0\n 16.7\n 8.9\n 8.1\n Hct\n 37.0\n 32.9\n 31.3\n 35.2\n Plt\n 437\n 379\n 306\n 395\n Cr\n 1.7\n 1.7\n 1.4\n 1.1\n 1.0\n TCO2\n 29\n Glucose\n 140\n 116\n 122\n 103\n 111\n Other labs: PT / PTT / INR:14.1/29.2/1.2, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:79.9 %, Lymph:15.2 %, Mono:3.2 %,\n Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2175-01-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 429998, "text": "Chief Complaint:\n 24 Hour Events:\n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 10:00 AM\n Pt attempted to get out of bed and pulled on foley catheter. This RN\n removed foley b/c pt c/o bladder spasm/pain.\n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 12:00 PM\n Pt pulled out PIV\n UNPLANNED LINE/CATHETER REMOVAL (NON-PATIENT INITATED) - At\n 05:00 PM\n Pt pulled out PIV, replaced w/20 gauge\n - extubated in AM\n - MRI/MRA - normal\n - remains on Acyclovir, d/c'd other antibitoics\n - ID recs - cont Acyclovir, awaiting MRI\n - Neuro - continue Keppra, defer to ID\n - ADAT\n - no issues overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 06:26 AM\n Vancomycin - 08:30 AM\n Ceftriaxone - 10:30 AM\n Acyclovir - 10:16 PM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 07:40 PM\n Heparin Sodium (Prophylaxis) - 10:17 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 36.3\nC (97.4\n HR: 86 (70 - 103) bpm\n BP: 137/86(98) {124/41(25) - 159/101(107)} mmHg\n RR: 28 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,384 mL\n 563 mL\n PO:\n 500 mL\n TF:\n IVF:\n 2,884 mL\n 563 mL\n Blood products:\n Total out:\n 3,810 mL\n 550 mL\n Urine:\n 3,810 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -426 mL\n 13 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 198 (198 - 198) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n FiO2: 40%\n SpO2: 96%\n ABG: ///31/\n Ve: 6.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 395 K/uL\n 12.4 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 6 mg/dL\n 104 mEq/L\n 141 mEq/L\n 35.2 %\n 8.1 K/uL\n [image002.jpg]\n 07:58 PM\n 03:29 AM\n 03:30 AM\n 03:58 PM\n 04:13 AM\n 04:26 AM\n WBC\n 20.0\n 16.7\n 8.9\n 8.1\n Hct\n 37.0\n 32.9\n 31.3\n 35.2\n Plt\n 437\n 379\n 306\n 395\n Cr\n 1.7\n 1.7\n 1.4\n 1.1\n 1.0\n TCO2\n 29\n Glucose\n 140\n 116\n 122\n 103\n 111\n Other labs: PT / PTT / INR:14.1/29.2/1.2, ALT / AST:19/22, Alk Phos / T\n Bili:66/0.4, Differential-Neuts:79.9 %, Lymph:15.2 %, Mono:3.2 %,\n Eos:1.4 %, Lactic Acid:0.9 mmol/L, Albumin:3.9 g/dL, LDH:356 IU/L,\n Ca++:9.1 mg/dL, Mg++:2.3 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 36 year old male without significant past medical history with fevers,\n altered mental status, and seizures.\n .\n # Fevers: Persistently high fevers in setting of myalgias, sore throat\n raises suspicion for viral prodrome and infection. Altered mental\n status and seizure x1 also causes concern for meningitis vs.\n encephalitis. The patient had LP at OSH but per neuro service would be\n useful to tap again and run for various viral serologies and infectious\n labs. CSF at OSH not consistent with bacterial infection. CXR appears\n clear w/question of haziness in LLL. Clinically lungs are clear on exam\n but noted this AM was increased sputum production, and sample was sent\n for culture. Given patient\ns history he is at increased risk for HIV\n (study pending at OSH). In addition to infectious causes (including\n HIV, EBV, HSV, Cryptococcus, etc) etiologies such as vasculitis and\n malignancy should be considered.\n - MRI/MRA to further work up anatomy and ? vasculitis\n - cont acyclovir, vancomycin, ampicillin, ceftriaxone for infectious\n etiology\n - repeat LP in am for cell count, protein, glucose, HSV PCR, HIV, Lyme,\n west PCR, enterovirus PCR\n - f/u stool cultures\n - f/u HIV labs\n -f/u ID and neurology recommendations\n - f/u blood cultures, urine culture and sputum cultures\n .\n # Respiratory failure: intubated in the setting of seizure with\n metabolic acidosis. CXR without significant pulmonary pathology\n although increasing sputum production.\n - RSBI, SBT qam\n - albuterol/atrovent nebs\n -if increasing secretions would hold off on extubation\n .\n # Seizures: Consider toxic-metabolic vs infectious etiology vs.\n structural abdormality of focus. Ct negative at outside hospital. MRI\n to be done today. Per neurology will start keppra and monitor for\n seizure activity with EEG.\n - check MRI\n - keppra\n - propofol drip for sedation\n - ativan prn for seizures\n -monitor and replete electrolytes\n -tox screen negative except for marijuana\n .\n # Altered mental status: given high fevers, altered mental status, and\n results of LP, suspect encephalitis. At OSH had no other evidence of\n infection. Tox + for cannaboids but unlikely to cause persistent\n altered MS. Also noted by family was change in behavior from his\n baseline since his return from overseas. Will continue to work up for\n toxic/metabolic and infectious etiologies.\n - fever treatment as above\n - f/u neuro consult\n - renal failure treatment as below\n .\n # ARF: At OSH, initial Cr 1.5 and improved this am to 1.2. Now again\n elevated to 1.7. Presumably had normal renal function prior. Initial\n ARF likely due to dehydration due to poor po intake and increased\n insensible losses from fevers. Also suspect acyclovir may have caused\n intrinsic renal damage.\n - aggressive IVF\n - renally dose meds\n - trend Cr\n -spin urine if ? acyclovir damage\n .\n # Sinus tachycardia: likely in the setting of fever and infection.\n Possible contribution of dehydration. Much better this morning.\n - IVF as above\n - monitor fever curve\n - ID treatment as above\n .\n # asthma: alb/atrovent nebs\n .\n # FEN: NPO for now, replete electrolytes prn, nutrition recs if\n prolonged intubation.\n -monitor INR (1.5), may need vitamin K if concern for bleed\n .\n # PPx: heparin sc. PPI while on vent. bowel regimen\n .\n # ACCESS: PIV x 3, aline\n .\n # CODE: FULL. Confirmed with mother, HCP\n .\n # COMM: (mother) , (c) ,\n girlfriend \n .\n # DISP: ICU\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2175-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 429999, "text": "History: Mr. is a 36 year old healthy male with recent travel\n to who is transferred from OSH with altered\n mental status, fevers, and seizures. History is obtained from family\n and medical records as patient is intubated and sedated. According to\n family, patient had been in his USOH until returning from .\n The day following his return, , he developed high fevers, as high\n as 104, typically beginning in the late afternoon and occurred daily.\n He had significant chills, night sweats, decreased appetite and po\n intake, and was awakening at night with nightmares and talking in his\n sleep which was atypical for him. He denied any HA, vision changes,\n numbness, weakness, slurred speech, abdominal pain, nausea, or\n vomiting. He did have one episode of diarrhea on . While in\n he did smoke various types of marijuana. Other exposures\n unknown. His family denies any significant animal exposures that they\n know about and do not think he traveled outside the city of .\n They did note that he was \"not himself\" saying he wanted to \"change his\n ways\" after returning from .\n Several days after developing fevers he also developed a sore throat\n and was given Amoxicillin by his PCP . Strep throat screen at\n that time was negative. On , he noted severe chills as well as\n diarrhea above. His girlfriend left him at home to go to work. He then\n apparently drove from to on . He was\n pulled over by the police for driving erratically and was then send to\n Hospital after providing bizarre answers to police.\n According to EMS who transported him, he could not answer any questions\n appropriately. His BG in the field was 130.\n In the OSH ED, AF, 127, 133/70, 18, 99% RA. His labs were relatively\n unremarkable with the exception of 8% bands. He had normal electrolytes\n and LFTs. A head CT was negative. He had an LP which showed 6 WBCs,\n 18RBC, glucose = 73, TP = 47, Gram stain pending, 86% lymphocytes on\n tube 1 on tube 4 0RBCs, 4 WBCs. He was started empirically on\n ceftriaxone and acyclovir for possible encephalitis. He was\n persistently febrile to 102. At 0500 am , he had a generalized\n tonic clonic seizure lasting 45 seconds and desaturated to the low 80s.\n ABG at that time was 7.05/38/60. The patient was then intubated. CXR\n showed no infiltrate.\n Pt was extubated on . remains on RA with sat 98-100%, no c/o of\n sob.\n Altered mental status (not Delirium)\n Assessment:\n Pt is A + O x 2, can state name and place, confused to time. . PERRL,\n MAEs normal strength, follows commands consistently but needs freq\n redirection. Cannot understand how to use call light. Pt\n intermittently pulling ECG leads, BP cuff despite explanation.\n Action:\n Bed low, locked, alarm on. Freq neuro checks, reorientation. PIV\n replaced (covered w/ arm ), pt voiding w/ urinal in bed.\n Response:\n Pt is free from falls. Head MRI found no evidence of abnormality.\n Plan:\n Freq asses MS, cont to tx for infection, and cx\ns. please sent throat\n viral culture awaiting special tube M4 Media . possible c/o to floo\n" }, { "category": "Radiology", "chartdate": "2175-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050891, "text": " 3:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines/tubes, infiltrates\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with altered mental status, intubated.\n REASON FOR THIS EXAMINATION:\n eval lines/tubes, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY:\n\n INDICATION: Altered mental status.\n\n Single portable AP view performed , at 04:00 hours is\n compared to the prior exam dated . The endotracheal tube is\n positioned 3.7 cm from the carina. The nasogastric tube extends below the\n diaphragm but the tip is not seen. The trachea and mediastinum are midline.\n The cardiac silhouette is not enlarged. There is no pulmonary infiltrate,\n vascular congestion, pleural effusion.\n\n IMPRESSION: ET tube and NG tube in good position.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050638, "text": " 8:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement, infiltrate\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with altered mental status, fevers, s/p intubation, transferred\n from OSH\n REASON FOR THIS EXAMINATION:\n ETT placement, infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JWK FRI 11:30 AM\n ETT lies 4.7 cm above the carina appropriately positioned. No pneumothorax.\n Mild right infrahilar peribronchial wall thickening.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old man with altered mental status following intubation.\n\n COMPARISON: None.\n\n FRONTAL CHEST RADIOGRAPH: An endotracheal tube is appropriately positioned\n 4.7 cm above the carina. A nasogastric tube courses over the expected\n location of the stomach. The cardiomediastinal silhouette is within normal\n limits. The pulmonary vasculature is normal. There is mild right infrahilar\n peribronchial wall thickening. No focal consolidations, pneumothorax, or\n pleural effusion.\n\n IMPRESSION:\n 1) Right infrahilar peribronchial wall thickening which can be seen in the\n setting of small airways disease.\n\n 2) Appropriate placement of endotracheal tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1050639, "text": ", MED MICU 8:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement, infiltrate\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with altered mental status, fevers, s/p intubation, transferred\n from OSH\n REASON FOR THIS EXAMINATION:\n ETT placement, infiltrate\n ______________________________________________________________________________\n PFI REPORT\n ETT lies 4.7 cm above the carina appropriately positioned. No pneumothorax.\n Mild right infrahilar peribronchial wall thickening.\n\n" }, { "category": "Radiology", "chartdate": "2175-01-21 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1050886, "text": " 1:22 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: acute infectious process, mass, edema\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man previously healthy admitted for altered mental status, seizure\n after week-long myalgias and fevers.\n REASON FOR THIS EXAMINATION:\n acute infectious process, mass, edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 12:15 PM\n Normal brain MRI, normal brain MRA.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with seizures after weeklong myalgias and\n fever, rule out mass or infection.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal\n images acquired following gadolinium. 3D time-of-flight MRA of the circle of\n obtained.\n\n FINDINGS: BRAIN MRI:\n\n There is no evidence of acute infarcts, mass effect, midline shift or\n hydrocephalus seen. There are no focal signal abnormalities or territorial\n infarcts. Following gadolinium, no abnormal enhancement is seen.\n\n IMPRESSION: No significant abnormalities on MRI of the brain with and without\n gadolinium.\n\n MRA OF THE HEAD:\n\n Head MRA demonstrates normal flow signal within the arteries of anterior and\n posterior circulation. Hypoplastic A1 segment of the left anterior cerebral\n artery is noted, which is a normal variation.\n\n IMPRESSION: Normal MRA of the head.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-01-21 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1050887, "text": ", MED MICU 1:22 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: acute infectious process, mass, edema\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man previously healthy admitted for altered mental status, seizure\n after week-long myalgias and fevers.\n REASON FOR THIS EXAMINATION:\n acute infectious process, mass, edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Normal brain MRI, normal brain MRA.\n\n\n" }, { "category": "ECG", "chartdate": "2175-01-19 00:00:00.000", "description": "Report", "row_id": 241103, "text": "Sinus tachycardia. RSR' pattern in leads V1-V2. Non-specific ST-T wave\nchanges in leads III and aVF. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2169-06-25 00:00:00.000", "description": "Report", "row_id": 1323662, "text": "7p-7a; Full assessment in flow sheet.\n\nNo neuro change. A+OX1. Calmer. Follow direction. No pain per pt. 1 period of anxiety - relief with ativan ivp. MAE - upper>lower. PERLA. VSS. Temp max 100. warm, dry, lower ext edema +1. clear lung sound in upper lobes. dimish at bases. no sob. less secretion - yellow/thick. obese abd. +BSX4. no bm. NG - bilious drainage, negative guiac, +placement. JP 1, 2 (brown drainage), 3 (SS) - site d/c/i. skin intact. Slept most of the night. AM lab done. lytes replace.\n\nPlan: Continue to monitor. Possible extubation.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-25 00:00:00.000", "description": "Report", "row_id": 1323663, "text": "Respiratory Care Note\n\nPt remains intubated and fully ventilated on AC settings. BLBS are coarse. Sxn for thick white secretions. RSBI completed on PSV 5=128. ABG shows adequate ventilation and oxygenation.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2169-06-25 00:00:00.000", "description": "Report", "row_id": 1323664, "text": "Resp care\nPt remains intubated & supported w/ mechanical ventilation\nCurrently A/C mode 550 x 12 5P 40%, ABG pending\nPt tolerated weaning to PSV 12/5 for 7 hrs\nVt- 350-400cc, RR- 20's, Placed on A/C mode to rest\nB/S clear-coarse, Sx copious amounts of thick white secretions\nPt treated w/ alb. mdi.\nPlan: continue support\n" }, { "category": "Nursing/other", "chartdate": "2169-06-26 00:00:00.000", "description": "Report", "row_id": 1323665, "text": "7p-7a; Full assessment in flow sheet.\n\nPt slept on/off most of the night. A+OX1. Good gag and cough reflex. Follow commands. MAE - stronger in upper than lower. Calmer. Only agitated with gagging - attempt to verbally calm - unsuccessful - ativan .5 mg ivp (good effect). Clear lung sound. Resting on A/C. Suction minimal - yellow/thick. VSS, afebrile. slight general edema. Obese abd. +BSX4. no bm. foley patent. skin intact. AM lab done.\n\nPlan; Continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-26 00:00:00.000", "description": "Report", "row_id": 1323666, "text": "Respiratory Care Note\n\nPt remains intubated and fully ventilated on AC settings. Sxn for moderate thick yellow secretions. BLBS remain coarse. RSBI completed on PSV 5=153.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2169-06-26 00:00:00.000", "description": "Report", "row_id": 1323667, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT VERY SLEEPY TODAY. SLPET MOST OF DAY. OPENS EYES TO STIMULATION. MAE. FOLLOWS COMMANDS.\n\nCV-LOW GRADE TEMP. HR/BP STABLE. SKIN W+D. +PP. PBOOTS ON. HCT 25 THIS AM. 1 U PRBCS GIVEN AND REPEAT HCT 31.\n\nRESP-REMAINS ON CPAP. ATTEMPTED TO WEAN TO PEEP 5, IPS 10 BUT PT VERY TACHYPNEIC WITH LOW TV'S. VENT RETURNED TO CPAP, 40%, PEEP 5, IPS 15. RR IMPROVED. SPONT TV 300-400'S. O2 SAT 100%. LS CLEAR, DECREASED AT BASES. SXN PRN FOR THICK WHITE SPUTUM.\n\nGI-ABD OBESE, SOFT. HYPO BS. NGT TO LWS WITH BILIOUS DRG. JP #1+2 WITH MURKY BROWN/GREEN DRG. JP #3 WITH SCANT SEROUSSANG. ABD DSG C/D/I. CON'T ON TPN.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE. LASIX GIVEN WITH + DIURESIS.\n\nCOMFORT-DENIES NEED FOR PAIN MED.\n\nENDO-SSRI.\n\nPLAN-CON'T WITH CURRENT PLAN. CON'T TO DIURES AND WEAN TO EXTUBATE.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-23 00:00:00.000", "description": "Report", "row_id": 1323657, "text": "Neuro: Pt sleeping on an off today. Opens eyes to voice, Pupils 3mm brisk. Nodding appropriately to yes/no questions. follows directions. Denies any pain. Med with ativan this am for anxiety, with good effect.\nCV: afebrile, HR 70-80's NSR with no ectopy. SBP stable with occasional episodes of hypertension with stimulation and anxiety. extremities warm with +PP. lytes replaced this am. Recieved 1dose lasix 20mg this am with good diuresis. Cont on TPN.\nRESP: lungs clear to dim at bases. Occasional suctioning of thick tan sputum, Attempted spontaneous breathing trial. Pt became tachypneic, and RISB >150. Vent remains unchanged.\nGI: abd large round with hypoactive BS. No stool today.\nGU: Foley patent draining excellent amounts of yellow with sediment urine.\nEndocrine: blood sugars elevated today. Sliding scale changed to tighter coverage.\nJP draining minimal amount of drg.\nPLAN: attempt to wean to extubate.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-24 00:00:00.000", "description": "Report", "row_id": 1323658, "text": "7p-7a; Full assessment in flow sheet.\n\nneuro; A+OX1-2. Follow commands. MAE - stronger upper than lower. Mouth words and nod appropriately. PERLA - 3 mm brisk. Strong gag and cough reflex. No pain per pt. Very anxious at time - Ativan .5 mg ivp given. Very anxious at midnight - RR40-50, HR 110', BP 200/50, gagging and attempt to pull out ET tube - ativan ivp given and change from AC to CPAP - good effect, pt able to sleep and breath easier.\n\ncv; NSR/ST without ectopy. Labile BP 90-200/50-60 (Dr. notify). afebrile. warm, dry, general edema +1, lower ext +2.\n\nresp; Coarse lung sound. dimish at bases. Suction and lavage - yellow/thick sputum. AC needed - attempt to return to CPAP - inc RR, TV, and coughing, pt have problem breathing.\n\ngu/gi; obese abd. +BSX4. no bm. foley patent - clear yellow urine. NG - bilious drainage. JP's site d/c/i - #1.2 - brown/thick drainage, #3 serosangious. Am Lab done.\n\nPlan; Continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-24 00:00:00.000", "description": "Report", "row_id": 1323659, "text": "Respiratory Care Note\n\nPt placed on full vent AC settings due to RR 40+, BP^^, and agitation. RR and BP came down immediately. Remained on AC settings for remainder of noc. SXN for moderate-large amount thick yellow secretions. BLBS are coarse. Some wheezes present. Albuterol MDI given with moderate effect. RSBI completed on PSV 5=149.\n\n , RRT\n\n\n" }, { "category": "Nursing/other", "chartdate": "2169-06-24 00:00:00.000", "description": "Report", "row_id": 1323660, "text": "Resp care\nPt remains intubated & supported w/ mechanical ventilation\nA/C mode 550 x 12 5P 40%, No ABG this shift\nB/S diminished, Wheezy, coarse-clear, Sx copious amounts of\nthick white secretions. Pt treated w/ Alb. mdi\nAttempted PSV mode, Pt didnt tolerate well, w/ increased RR\nPlaced back on A/C mode\nPlan: continue support\n" }, { "category": "Nursing/other", "chartdate": "2169-06-24 00:00:00.000", "description": "Report", "row_id": 1323661, "text": "FOCUS-CONDITION UPDATE\nDATA-PT ROUSES EASILY TO VERBAL STIMULI, FOLLOWS SIMPLE COMMANDS. PT\nCALM THE DAY. PT REMAINS ON 40%/A/C RATE OF 12. PT SUCTIONED FOR THICK WHITE SECRETIONS. PT CONTINUES ON TPN.\n\nACTION-NO VENT CHANGES TODAY. PT GIVEN LASIX 20MG IV X1 TODAY.\nABD DRESSING CHANGED X1 FOR SM AMT SEROUS DRAINAGE.\n\nRESPONSE-PT DIURESED WELL FROM LASIX.\n\nPLAN-CONTINUE TO MONITOR CLOSELY. NEW ALINE PER RESIDENT.\n\n" }, { "category": "Nursing/other", "chartdate": "2169-06-22 00:00:00.000", "description": "Report", "row_id": 1323651, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT IS A 72 Y/O FEMALE ADMITTED TO ON WITH GALLSTONE PANCREATITIS, PANCREATIC PSEUDOCYST. PT TO OR ON FOR PANCREATIC DEBRIDEMENT, ABSCESS DRAINAGE AND OPEN CHOLE. PT INITIALLY TO PACU THEN TX TO ICU ON . SEE CHART FOR PMH. PE AS FOLLOWS:\n\nNEURO-PT AWAKE, NODS HEAD APPROP. MAE. FOLLOWS COMMANDS.\n\nCV-AFEB. HR/BP STABLE. SKIN W+D. +PP. PBOOTS ON. HCT LOW, TEAM AWARE.\n\nRESP-NO VENT CHANGES OVERNOC. REMAINS ON CPAP, 40%, PEEP 5, IPS 10. O2 SAT 98%. SPONT TV 350-400'S. RR WNL, BUT TACHYPNEIC WHEN STIMULATED. ABG ACCEPTABLE. LS CLEAR TO COARSE, DECREASED AT BASES. SXN PRN FOR THICK TAN SPUTUM.\n\nGI-ABD OBESE, SOFTLY DISTENDED. HYPO BS. NGT TO LWS WITH SCANT AMT BILIOUS DRG. JP #1+#2 WITH THICK DARK BROWN/GREEN DRG. JP#3 WITH SEROUSSANG DRG. INCISION WNL.\n\nGU-VOIDING VIA FOLEY >20CC/HR OF CL YELLOW URINE.\n\nCOMFORT-NODS HEAD \"NO\" WHEN ASKED IF IN PAIN. APPEARS COMFORTABLE.\n\nENDO-SSRI.\n\nPLAN-CON'T WITH CURRENT PLAN. MONITOR FLUID STATUS. ? WEAN TO EXTUBATE. ASSESS PAIN.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-22 00:00:00.000", "description": "Report", "row_id": 1323652, "text": "Resp. care note - Pt. remaines vented, suctioned for yellow secritiones.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-22 00:00:00.000", "description": "Report", "row_id": 1323653, "text": "Neuro: alert and nodding to questions appropriately. Denies pain. Pt appears very anxious. Started on Ativan PRN with good effect.\nCV: afebrile, Hemodynamically stable. +PP, Recieved 1u PRBC at 1700 for repeat HCT 27.\nRESP: lungs clear to dim at bases. No vent changes today. Occasional suctioning of thick tan sputum. Will cont to become tachypneic with stimulation.\nGI: abd large round with hypoactive BS. Remains NPO. NGT draining small amounts of bilous drg.\nGU: foley draining good amounts of clear yellow urine today. Trending down this afternoon.\nEndocrine: blood sugars slightly elevated. requiring minimal coverage per RISS.\nJP #1&#2 cont to drain bilious drg. #1 draining serosang.\nStarted on Vanco this eve for entero-cocci from pancreatic debridment\n" }, { "category": "Nursing/other", "chartdate": "2169-06-23 00:00:00.000", "description": "Report", "row_id": 1323654, "text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient remains on Cpap/ps with Ip of 10 Peep 5 and fio2 at 40%. Spontaneous tidal volumes are around 300-350cc with RR in the 20's. Breathsounds are coarse at times. Albuterol given. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. RSBI 144 this am.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-23 00:00:00.000", "description": "Report", "row_id": 1323655, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT SLEPT MOST OF NOC. OPENS EYES SPONT. MAE. FOLLOWS COMMANDS.\n\nCV-AFEB. HR/BP STABLE. SKIN W+D. +PP. PBOOTS ON. HCT IMPROVED AFTER PRBC TRANSFUSION. LYTES REPLETED PRN.\n\nRESP-NO VENT CHAGNES OVER NOC. REMAINS ON CPAP, 40%, 5 PEEP, 10 IPS. O2 SAT 99%. SPONT TV 300'S. RR WNL, BUT CON'T TACHYPNEIC WHEN STIMULATED. LS CLEAR, DECREASED AT BASES. SXN FOR SM AMT THICK YELLOW SPUTUM.\n\nGI-ABD OBESE, SOFTLY DISTENDED. +HYPO BS. NGT TO LWS WITH BILIOUS DRG. JP #1+#2 CON'T WITH MURKY DARK BROWN/GREEN DRG. JP #3 WITH SEROUSSANG DRG. INCISION WNL. CON'T ON TPN.\n\nGU-VOIDING VIA FOLEY CL YELLOW URINE.\n\nCOMFORT-DENIES PAIN. ATIVAN PRN FOR ANXIETY.\n\nENDO-SSRI.\n\nPLAN-CON'T WITH CURRENT PLAN.\n\n" }, { "category": "Nursing/other", "chartdate": "2169-06-23 00:00:00.000", "description": "Report", "row_id": 1323656, "text": "Resp. care note - Pt. remaines intubated and vented, suctioned for yellow secritiones.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-22 00:00:00.000", "description": "Report", "row_id": 1323650, "text": "PT.REMAINS ON CPAP+PS, RSBI-100, ABG ACIDOTIC, MDI ALBUTEROL GIVEN, ATTEMPT TO EXTUBATE TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-27 00:00:00.000", "description": "Report", "row_id": 1323668, "text": "CONDITION UPDATE\nASSESSMENT:\nPT OPENING EYES TO VOICE AND FOLLOWING COMMANDS. MOVES ALL EXTREMITIES EQUALLY, ARMS CURRENTLY RESTRAINED. ROUTINE CXR DONE & PT LEFT UNRESTRAINED BY RADIOLOGY , PT PULLED OUT NGT. PT FOUND TO BE TACHYPNEIC WITH RR IN 50'S AND SP02 DROPPED TO 68%. SUCTIONED FOR THICK WHITE SPUTUM, GIVEN ATIVAN, DR. NOTIFIED AND IN TO EVALUATE PT. VENT SETTINGS CHANGED TO ASSIST CONTROL, ABG ACCEPTABLE. LS MOSTLY CLEAR AND BREATHING NOW UNLABORED. A-LINE POSITIONAL, FOLLOWING CUFF PRESSURES. MAINTAINING ADEQUATE HOURLY URINE OVERNIGHT, NO LASIX GIVEN. NGT REPLACED BY DR. .\nPLAN:\nCONTINUE TO DIURESE & WEAN VENT AS TOLERATES. RETURN TO CPAP WITH 15 PRESSURE SUPPORT AND 5 PEEP TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-27 00:00:00.000", "description": "Report", "row_id": 1323669, "text": "resp care note:\n\npt had episode of tachypnea followeed by desaturATION TO 70'S. SHE WENT ON A/C VENTILATION UNTIL 6AM. AT THNIS TIME A RSBI IS DONE AND SHE IS ON PSV 15/5.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-27 00:00:00.000", "description": "Report", "row_id": 1323670, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT AWAKE. MAE. FOLLOWS COMMANDS. PERRL. FREQ ATTEMPTING TO PULL OUT TUBES/LINES.\n\nCV-AFEB. HR/BP STABLE. HCT STABLE. SKIN W+D. +PP. PBOOTS ON. ALINE VERY DAMPENED. TEAM TO ATTEMPT NEW ALINE PLACEMENT.\n\nRESP-NO VENT CHANGES MADE TODAY. O2 SAT 100%. SPONT TV 400'S. PT WITH SOME EPISODES THIS AM OF APNEA FOLLOWED BY TACHYPNEA. EPISODES HAVE SINCE STOPPED. PT WITH TACHYPNEA WHEN STIMULATED. ABG ACCEPTABLE. LS COASE. DECREASED AT BASES. SXN PRN FOR THICK WHITE SPUTUM.\n\nGI-ABD OBESE. NGT TO LWS WITH BILIOUS DRG. +BS. CON'T NPO ON TPN. JP#1+2 WITH MURKY BROWN DRG. JP#3 WITH SEROSANG DRG. ABD DSG C/D/I.\n\nGU-GIVEN DOSE OF LASIX THIS AM WITH + DIURESIS. FOLEY NOTED TO BE OUT WITH LARGE AMT URINE ON BED. FOLEY REPLACED. U/O CLEAR YELLOW.\n\nCOMFORT-DENIES PAIN. APPEARS COMFORTABLE.\n\nENDO-SSRI.\n\nPLAN-CON'T WITH CURRENT PLAN. AWAIT NEW ALINE. CON'T WITH DIURESIS AND WEAN TO EXTUBATE WHEN APPROP.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-28 00:00:00.000", "description": "Report", "row_id": 1323671, "text": "Resp Care Note, Rested on CPAP/ PSV 15/5. bAck down TO 10/5 0400.Suctioned for mod amts thick white secretions. MDI'S given. RSBI done on 0 peep 5 Ips -123.3. Breathing in the 30's. Will cont to monitor resp status for further weaning.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-28 00:00:00.000", "description": "Report", "row_id": 1323672, "text": "condition update\nNEURO: OPENS EYES TO VERBAL STIMULI, FOLLOWS COMMANDS, MOVES ALL EXTREMITIES WITH EQUAL STRENGTH. CONTINUES TO TRY TO PULL TUBES OUT WHEN NOT RESTRAINED.\nCV: AFEBRILE, HR AND BP STABLE- SEE CAREVUE FOR SPECIFICS\nRESP: RESTED ON PS 15 OVERNIGHT. IPS DROPPED TO 10 AT 0330 WITH INCREASE IN RESP RATE TO LOW 30'S AND DROP IN SPONT TV FROM 400'S TO 275-350. BS COARSE. SX FOR THICK WHITE SECRETIONS.\nGI: ABD OBESE, SOFT BUT NON-TENDER, + BS AND SM AMT LOOSE BROWN STOOL. NGT PATENT AND DRAINING BILIOUS.\nGU: LASIX 20MG IV WITH EXCELLENT DIURESIS. PT LEAKING URINE AROUND FOLEY- 5CC NS ADDED TO BALLOON OF FOLEY WITH NO FURTHER LEAKAGE NOTED\nENDO: BS COVERED BY SLIDING SCALE.\nSKIN: ABD DRESSING DRY AND INTACT.\nA: HEMODYNANICS MONITORED, SX PRN\nR: CONTINUE TO DIURESIS AS ORDERED, ATTEMPT FURTHER VENT WEAN AS TOL\n" }, { "category": "Nursing/other", "chartdate": "2169-07-02 00:00:00.000", "description": "Report", "row_id": 1323687, "text": "nursing note\nNeuro: more alert today, following commands. Afebrile. Denies pain\n\nCV:SR, rare PVC's. SBP WNL, aline dampens. P-boots and multipodus boots on. +PP.\n\nRESP:LS coarse to clear, dimnished at bases. Suctioned for thick white secretions mod amts.\n\nGI:Abd soft, nt,nd. +loose BM x2, FIB placed. JP x2 drng murky grey drng. TPN. NGT to LWS bilious drng.\n\nGU:foley patent clear yellow urine.\n\nSKIN:intact. Incision with OTS, RLQ with erythema, MD iwth no return call. MD aware.\n\n" }, { "category": "Nursing/other", "chartdate": "2169-07-03 00:00:00.000", "description": "Report", "row_id": 1323688, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: OPENS EYES TO VOICE. FOLLOWS COMMANDS. MAE. PERRL. DENIES PAIN. LORAZAPEM X1 FOR SLEEP WITH MIN EFFECT.\nRESP: LS CLEAR BUT DIM AT BASES. SM AMT WHITE SPUTUM VIA ET. ABGS STABLE. PS WEANED TO 8 THIS AM. RR 20S-30S. REPEAT ABG PENDING.\nCV: AFEBRILE. PERIOD OF VENTRICULAR BIGEMINY WITH ET SUCTION. RESOLVED WITHOUT INTERVENTION. EKG AND LYTES WNL. NSR CONTS THROUGH NOC WITH OCCASIONAL PVCS. BP STABLE.\nGI: SM AMT LOOSE BROWN STOOL VIA FIB.\nGU: CLEAR YELLOW U/O VIA FOLEY.\nENDO: FABG COVERED PER RISS.\nSKIN: ABD INC OTA WITH STAPLES INTACT. AM AREA ERYTHEMA AT RLQ, DRAINING MOD AMT SEROUS FLUID. DSD APPLIED. JP #1 WITH MOD AMT GREENISH, SEROUS O/P. JP #2 WITH SM AMT TAN, CLOUDY O/P.\nPLAN: CONT TO MONITOR. INCREASE ACTIVITY AS TOLERATED. WEAN PS AS TOLERATED. MONITOR WOUND DRG AND REDNESS. CONT PER CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2169-07-03 00:00:00.000", "description": "Report", "row_id": 1323689, "text": "Resp Care\nPt. remains intubated on vent. PSV lowered this morning pt. tolerated change well w/o much change in VT/MV 200-300cc.\nabg: ess. normal A/B balance with hyperoxia.\nBs: diffuse exp. wheezes occ. tx'd with albuterol. Sxn'd x1 for sm. yellow, pt. had episode on ventricular bigeminy.\nPlan:extubate and schedule a trach if pt. doesn't tolerate.\n" }, { "category": "Nursing/other", "chartdate": "2169-07-03 00:00:00.000", "description": "Report", "row_id": 1323690, "text": "nursing note\nNeuro:alert, confused to events elading ot hospital and trying to get OOB to see daughter. Doesn't always undrestand where she is. Afebrile.\n\nCV:SR, PVC's. SBP WNL. OOB to chair, tolerated poorly- needs PT and proabble lift in future. MD aware to order PT consult. P-boots on. +pp. minimal edema. Central line d/c'd. PICC intact.\n\nRESP:LS clear, thick white sputum expectoarted into yankauer.\n\nGI:abd soft, nt,nd. JP x2 drng murky tanish drng. NGT with impact with fiber at 10cc/hour. loose brown stool via FIB. TPN infusing.\n\nGU:foley patent clear yellow urine.\n\nSKIN: incision opened on LLQ and RLQ, drng sero-sang. Wound culture sent.\n\nSOCIAL:daughter and sister calling for updates. SW speaking with daughter .\n\n" }, { "category": "Radiology", "chartdate": "2169-06-19 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 825409, "text": " 10:14 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: INFECTED PANCREATIC PSEUDOCYST, PRE-OP FOR PANCREATIC DEBRIDEMENT\n Admitting Diagnosis: INFECTED PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infected pancreatic pseudocyst. Preoperative.\n\n COMPARISON: .\n\n STANDARD PA AND LEFT LATERAL UPRIGHT VIEWS: There is now a fairly small\n pleural effusion at the left lung base, larger than on the prior study. This\n is associated with some minor atelectasis in the basal segments of the left\n lower lobe. No other significant cardiopulmonary abnormality is identified. A\n left upper extremity central line is noted with its tip well positioned in the\n mid SVC.\n\n IMPRESSION: Increasing size of left pleural effusion associated with left\n lower lobe atelectasis.\n\n" }, { "category": "Nursing/other", "chartdate": "2169-07-01 00:00:00.000", "description": "Report", "row_id": 1323681, "text": "Resp Care Note:\n\nPt placed on CPAP/PSV at 5/15. Currenlty her rr is in the 30-35 range although ABG are okay. She has significant amount of secretions and her breathing rate has been irregular with periods of apnea earlier in the evening. If wean does not progress successfully after tonight, have suggested MMV could be an alternative.\n" }, { "category": "Nursing/other", "chartdate": "2169-07-01 00:00:00.000", "description": "Report", "row_id": 1323682, "text": "ADDEN :Albuterol MDI given ~ Q6 hrs, B/S are course but few wheezes.\n" }, { "category": "Nursing/other", "chartdate": "2169-07-01 00:00:00.000", "description": "Report", "row_id": 1323683, "text": "condition update\nD: pt opens eyes to name, follows commands. ativan x1 for agitation. pt changed to cpap with 15 of pressure support. suctioned for moderate amts of thick white sputum. bs are coarse and diminished in the bases. temp max 100. urine output remains adequate. abd incision is clean and dry and open to air, jp's to bulb suction. 1 and 2 are brown and 3 is serous/sanginous. no areas of breakdown noted. tpn is infusing.\na: aggressive pulmonary toilet. abg drawn on cpap with pressure support.\nr: abg good. with activity and stimulation pt becomes. tachypnic but resp rate back down when stimulation removed. pt with large amt of thick white secretions. wound appears clean. aline waveform dampened and continue to go by cuff pressure.\n" }, { "category": "Nursing/other", "chartdate": "2169-07-01 00:00:00.000", "description": "Report", "row_id": 1323684, "text": "nursing note\nNeuro:alert or sleeps and easily arouses to voice. follows commands- restarined due to pulling at ngt and et tube. febrile to 100.9.\n\nCV:SR, PVC's. SBP WN:. Aline dampens but does draw back blood. P-boots on. min pedal edema.\n\nRESP:LS coarse, thick white sputum. bronch done- tol well, spec sent.\nremains on CPAP. PS 15. peep 5. periods of tachypnea assoc with RN in room. ? anxiety.\n\nGI:Abd large, soft, nt. incis OTA with staples. area of redness at l side of incision. 3 JP's remain in drng cloudy tan. BM x2. NGT to LWS drng bilious drng.\n\nGU:foley patent clear yellow urine adeq amounts.\n\nSKIN:intact.\n\nSOCIAL: fmaily in and visiting. Pleasant and approp with care.\n" }, { "category": "Nursing/other", "chartdate": "2169-07-02 00:00:00.000", "description": "Report", "row_id": 1323685, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLO0WSJEET FOR SPECIFICS.\nNEURO: PT DOZING ON/OFF THROUGH NOC. OPENS EYES TO VOICE. DENIES PAIN. MAE. FOLLOWS COMMANDS. PERRL.\nRESP: LS COARSE, DIM AT BASES. ET SUCTIONED FOR SM AMTS THICK WHITE SPUTUM, LARGER AMTS YELLOW SPUTUM SUCTIONED AFTER AMBU. ABG STABLE.\nCV: TMAX 99.4 PO. NSR, OCCASIONAL PVCS. BP STABLE 130S TO 150S VIA NBP. ART LINE DAMPENED BUT ABLE TO DRAW BLOOD.\nGI: ABD SOFTLY DISTENDED. FAINT BS. NGT TO LCWS WITH BILIOUS O/P. NPO. MOD LIQUID BM, BROWNISH GREEN.\nGU: POS EFFECT FROM LASIX DOSE OF PREVIOUS SHIFT. FLUID BAL NEG >800CC AT MN. CLEAR YELLOW U/O VIA FOLEY. CURRENTLY POS >150CC FOR DAY.\nENDO: FSBG CCOVERED PER RISS.\nSKIN: JPS WITH SM AMT SEROUS O/P. ABD INC OTA WITH STAPLES INTACT. SL PINK AT RLQ.\nPLAN: CONT TO MONITOR. CONT PULM TOILET. CONT PER CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2169-07-02 00:00:00.000", "description": "Report", "row_id": 1323686, "text": "RESP CARE NOTE:\n\nPT CONTINUES ON PSV 15/5 PEEP. RR QUICKLY MOVES INTO 40'S UPON ATTEPT TO DO RSBI. PT STILL REQUIRING REL FREQUENT SUX FOR LARGE AMTS THK YELLOW. ETT RETAPED AND REPOSD EARLIER IN SHIFT. CHANGED.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-29 00:00:00.000", "description": "Report", "row_id": 1323676, "text": "Please see ICU flowsheet for specific values.\nNeuro: Pt was calm and cooperative during shift, unable to speak secondary to ET tube, but responds to voice and will respond appropriately to questions. PERRLA.\nCV: blood pressure as per baseline- pt line needed frequent repositioning for correct bp values. CVP 3-5 during day. HR- 70's-80's. Administered IV lopressor a/o.\nResp: Pt on CPAP wit rr-22-28 with low tidal volume and RISB 122. Pt suctioned throughout the shift due to large amounts of thick white secretions in lungs and back of mouth; Coarse lung sounds throughout lung bases. Mouth care given. More secretions noted pt moved oob to chair. Pt with improving ABG this am. Plan to start weaning pt off of vent.\nMob: pt oob to chair with lift and assist x 3.\nRenal: foley draining adequate amounts of CYY with slight amount of sediment in am. Admin 20 mg IV lasix this am to aid in diuresis; pt responded well.\nNut: pt has TPN being infused, and will continue.\nSkin: transverse abdominal incis ota with staples w/o s/s infection. JP #1 CDI with drainage sponge; draining small amounts of thick brown drainage. JP #2 CDI with drainage sponge CDI with scant amount thick tan secretions. JP #3 CDI with drainage sponge; draining small amounts serosang drainage. A-line dressing changed- CDI. CVL dsg changed-CDI.\nPlan: Cont to get pt OOB, continue with good pulmonary toilet and chest PT. Wean as tolerated from vent, family supportive.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-30 00:00:00.000", "description": "Report", "row_id": 1323677, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned lrg amts thick white secretions. MDI'S given. Unable to complete RSBI due to tachypnea RR 50's.Will cont to monitor resp status for further weaning.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-30 00:00:00.000", "description": "Report", "row_id": 1323678, "text": "Resp Care Note, Pt placed on A/C for increased RR into the 50's. Will cont to monitor for further weaning.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-30 00:00:00.000", "description": "Report", "row_id": 1323679, "text": "NEURO; ALERT TO PERSON, FOLLOWS COMMANDS, MAE, MEDIC WITH ATIVAN 0.5 MGM IV THIS AM FOR ANXIETY AND OVERBREATHING WITH VENT\n\nCARDIOVASCULAR; TEMP 98.9 AXILLARY, EXTREMITIES WARM, HR 80'S SR, CVP 5-8\n\nRESPIR; SUCTIONED FOR MODER THICK YELLOW-WHITE SECRETIONS FREQUENTLY, COARSE BREATH SOUNDS THROUGHOUT, REMAINS ON C-PAP WITH SPONT TV 350-480'S\n\nGI; NG TO LWSX, 450 CC BROWN BILIOUS MATERIAL\n\nENDOCRINE; BS 178 AT MIDNOC AND COVERED WITH SLIDING SCALE, AWAITING AM LABS\n" }, { "category": "Nursing/other", "chartdate": "2169-06-30 00:00:00.000", "description": "Report", "row_id": 1323680, "text": "Condition Update A:\nPlease refer to care view and remarks for details.\nNEURO: Alert for short periods, otherwise easily arousable. Cont's with occ bouts of anxiety treated with Ativan 0.5mg IVP x2 with good effect. Denies c/o pain, no grimacing noted with repositioning.\nCV: Tmax 100.0 down to 99.3. HR NSR no ectopy. A-line changed over wire due to dampend wave form and inabilty to draw ABG's/labs. Following NIBP for BP as a-line dampened. WBC improving.\nRESP: No ventilator changes today. Breathing over the ventilator, good TV. Suctioned/lavaged every two hours for white thick occ thin secretions.\nGI/GU: NGT draining bilious/brown output. TPN infusing. Checking glucose levels and treating per RISS. No stool or flatus. Diuressed after Lasix 20mg IV admin. No leakinage from foley.\nSKIN: ABD incision with staples C/D/I OTA. Sheepskin underheels.\n\nPLAN: Monitor resp status, attempt to continue vent weaning as pt tolerates. Monitor hemodynamics. Cont with ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-28 00:00:00.000", "description": "Report", "row_id": 1323673, "text": "Condition Update A:\nPlease refer to careview and remarks for details.\nNEURO: Denies pain. Ativan 0.5mg IVP x2 for anxiety with good effect. Follows commands, MEA spontaneously. Continuing with bilat wrist restraints as pt trying to pull at ETT and NGT when wrists unrestrained.\nCV: Tmax 100.3, down to 99.3. NSR no ectopy. BP WNL.\nRESP: Frequent suctioning fo rwhite thick secretions. Tol CPAP with PS 10 with resp rate 28-28. SICU team aware. Tol CPT x2.\nGI/GU: TPN infusing. Monitoring glucose levels and treating per RISS. Small smear brown guaiac negative stool. Lasix x1 admin this morning, and Diamox started to day for diuressing with good effect.\nSKIN: ABD inc C/D/I, slightly pink at incision. JP #1 insertion site pink and with small amount serosang drainage. JP 2 and # insertion site s slightly pink and dry. OOB for 1.5 hours to chair via lift.\n\nPLAN: Monitor resp status, suction, may require being rested overnight. Monitor glucose levels, treat per RISS. Monitor skin, incision, and JP sites. Cont with ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2169-06-29 00:00:00.000", "description": "Report", "row_id": 1323674, "text": "Resp Care Note,Pt remains on current vent settings.See vent flow sheet for details.Suctioned lrg amts thick yellow secretions.Good ABG'S.MDI'S given.Temp 99.6.RSBI 102.9\n" }, { "category": "Nursing/other", "chartdate": "2169-06-29 00:00:00.000", "description": "Report", "row_id": 1323675, "text": "condition update\nNEURO: OPENS EYES TO NAME, FOLLOWS COMMANDS, MOVES ALL EXTREMITES ON BED WITH EQUAL STRENGTH. PT REQUIRES BILAT WRIST RESTRAINTS TO PREVENT HER FROM PULLING AT ETT AND NGT.\nCV: T MAX 99.6. OTHER VSS- SEE CAREVUE FOR SPECIFICS.\nRESP: CPAP WITH 10 IPS ALL SHIFT. SPONT TV 270-400. SATS 98%. BS COARSE, SX FOR LARGE AMTS THICK WHITE SECRETIONS. RSBI 120.9 THIS AM.\nGI: NPO, NGT PATENT AND DRAINING BILIOUS. ABD SOFT AND NON-TENDER, +BS\nGU: DIAMOX X 1, NO FURTHER LASIX DOSES , HUO ADEQUATE.\nPLAN: CONTINUE TO WEAN AS TOLERATED, SX PRN, CONTINUE TO MONITOR FLUID STATUS CLOSELY- ? FURTHER LASIX/DIAMOX DOSES\n" }, { "category": "Nursing/other", "chartdate": "2169-07-04 00:00:00.000", "description": "Report", "row_id": 1323691, "text": "condition update\nD; pt is alert and confused. trying to get out of bed. moves all extremities. pt remains extubated. appears comfortable. o2 sat on r/a is 97%. pt receiving prn albuterol nebs. bs are clear and diminished in the bases. coughing and raising thick white sputum. pt denies any pain. aabd wound is erythemaous and open. draining serous/sanginous drainage. tf at 10cc /hr of impact with fiber. ngt is patent. positive bowel sound. fecal bag intact. draining brown liquid stool.\na: aggressive plumnonary toilet. reorient frequently. tf at 10cc/hr till reevaluated in the am.\nr: doing well extubated. pt appears comfortable. 02 sat 96% on r/a. pt tolerating albuterol nebs. pt sleeping in short naps. pt still confused but easily reoriented.\n" }, { "category": "Radiology", "chartdate": "2169-06-16 00:00:00.000", "description": "US GUID FOR VAS. ACCESS", "row_id": 825203, "text": " 3:33 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC for long-term nutrition needs\n Admitting Diagnosis: INFECTED PANCREATIC PSEUDOCYST\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with\n REASON FOR THIS EXAMINATION:\n please place PICC for long-term nutrition needs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Long-term TPN.\n\n RADIOLOGISTS: Procedure was performed by Dr. (resident), Dr. \n (resident), and Dr. , the attending radiologist, who\n supervised the procedure.\n\n PROCEDURE/FINDINGS: The patient was placed supine on the angiographic table,\n and prepped and draped in the usual sterile fashion. As no vein was found\n suitable clinically for access, focused ultrasound examination was performed;\n the left brachial vein was imaged and found to be widely patent. Hard copy\n ultrasound images were taken of the left brachial vein before venopuncture.\n The skin and subcutaneous soft tissues overlying the left brachial vein were\n anesthetized using 3 cc of 1% lidocaine. Using continuous ultrasonographic\n guidance, a micropuncture needle was advanced into the left brachial vein. A\n 0.018 guidewire was then advanced through the needle to the level of the right\n atrium. The needle was removed and a skin was made. Next the needle was\n exchanged for a micropuncture sheath set. The catheter length was measured to\n be 41 cm, and the PICC was trimmed appropriately. The inner portion of the\n sheath was removed and the PICC was advanced over the wire. The wire and peel-\n away sheath were then removed. The catheter was secured to the skin using\n StatLock and OpSites. There were no immediate complications. A fluoroscopic\n spot image taken after catheter placement documented successful placement\n within the central portion of the superior vena cava (SVC), just above the\n cavoatrial junction.\n\n IMPRESSION: Successful placement of a 41 cm long, 5 French Vaxcel dual-lumen\n PICC in the left brachial vein. The tip is at the distal SVC at the level of\n the cavoatrial junction. The catheter is ready for immediate use.\n\n" }, { "category": "Radiology", "chartdate": "2169-07-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 826750, "text": " 9:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pnuemonia\n Admitting Diagnosis: INFECTED PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p pancreatic debridement\n\n REASON FOR THIS EXAMINATION:\n ? pnuemonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath post pancreatic debridement.\n\n COMPARISON: .\n\n FINDINGS: The ETT tip is slightly low, 1.6 cm above the carina. A right IJ\n central venous line is seen in the mid SVC. The line appears kinked near the\n expected skin entry site. There is persistent opacity in the left\n retrocardiac region. There is no CHF or pneumothorax. No free air is seen\n beneath the diaphragms.\n\n IMPRESSION: 1. Persistent left lower lobe opacity.\n 2. ETT tip slightly low; this could be pulled back 1 to 2 cm for better\n placement.\n\n" }, { "category": "Radiology", "chartdate": "2169-06-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 826219, "text": " 8:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf, infiltrate\n Admitting Diagnosis: INFECTED PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p pancreatic debridement\n\n REASON FOR THIS EXAMINATION:\n eval for chf, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post pancreatic debridement. Evaluate for CHF and\n infiltrate.\n\n Comparison is made to the prior chest x-ray on .\n\n SUPINE AP CHEST: There is again present an endotracheal tube, right internal\n jugular catheter, left PICC line and NG tube in stable position. The heart,\n mediastinal and hilar contours are unchanged in appearance. There is\n persistent left lower lobe collapse/consolidation and a small left-sided\n pleural effusion. There is no overt evidence of failure.\n\n IMPRESSION: Persistent left lower lobe atelectasis/consolidation and small\n effusion with no other significant changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2169-06-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825978, "text": " 9:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval failure\n Admitting Diagnosis: INFECTED PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p pancreatic debridement\n\n REASON FOR THIS EXAMINATION:\n eval failure\n ______________________________________________________________________________\n FINAL REPORT\n History of pancreatic debridement.\n\n Endotracheal tube is 1.5 cm above carina. Right jugular CV line is in region\n of cavoatrial junction. NG tube extends below diaphragm. No pneumothorax. For\n technique heart size is normal. There is an ill-defined opacity at the left\n base likely due to a combination of atelectasis and possible small left\n pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2169-07-06 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 827270, "text": " 1:29 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PO and IV Contrast. Extent of remnant pseudocyst and strandi\n Admitting Diagnosis: INFECTED PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p debridement and drainage of infected pancreatic\n pseudocyst on \n REASON FOR THIS EXAMINATION:\n PO and IV Contrast. Extent of remnant pseudocyst and stranding?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Post-debridement and drainage of infected pancreatic pseudocyst\n on . Evaluate extent of remnant.\n\n COMPARSION: 4/16/04/\n\n TECHNIQUE: Non-contrast and post-contrast images were obtained from the lung\n bases to pubic symphysis.\n\n CT ABDOMEN W&W/0 CONTRAST: There has been interval development of a trace\n left pleural effusion. There is left lower lobe patchy opacity. The right\n lung base is clear. Within the posterior portion of the right lobe of the\n liver there is a hypodense lesion which fills in with contrast, consistent\n with a hemangioma. The appearance is unchanged compared to prior studies. No\n other focal liver lesions are detected. The gallbladder has been resected.\n There are no calcifications within the pancreas. Two surgical drains are\n present adjacent to the pancreas, one coiled near the tail of the pancreas,\n the other located by the mid-body of the pancreas. There is trace amount of\n fluid near the tail of the pancreas adjacent to the medial aspect of the\n spleen. The large fluid collection tracking adjacent to the body of the\n pancreas, posterior to the stomach is no longer evident. The pancreas\n enhances normally. There is moderate stranding throughout the mesentery\n adjacent to the pancreas. There is stranding within the subcutaneous tissues.\n No discrete fluid collections are identifiedl The spleen, right adrenal\n gland and intraadominal bowel loops are unremarkable. Again demonstrated are\n several focal areas of low attenuation within the right kidney,unchanged\n compared to prior study and too small to characterize. The left kidney has\n been resected. The left adrenal gland appears thickened and unchanged.\n\n CT PELVIS W/CONTRAST: The uterus, urinary bladder and intrapelvic bowel loops\n are unremarkable. There is a small amount of free fluid within the pelvis. No\n significant pelvic adenopathy.\n\n There are no suspicious osseous lesions.\n\n IMPRESSION: Interval placement of two surgical drains adjacent to the\n pancreas. Minimal residual fluid at the level of the pancreatic tail. No new\n fluid collections are identified. There is moderate stranding within the\n (Over)\n\n 1:29 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PO and IV Contrast. Extent of remnant pseudocyst and strandi\n Admitting Diagnosis: INFECTED PANCREATIC PSEUDOCYST\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mesentery and subcutaneous tissues, consistent with inflammatory change likely\n related to the recent surgery.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2169-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 825571, "text": " 3:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R IJ cvl, UPRIGHT CXR please, eval fot ptx, line positio\n Admitting Diagnosis: INFECTED PANCREATIC PSEUDOCYST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p pancreatic debridement\n REASON FOR THIS EXAMINATION:\n s/p R IJ cvl, UPRIGHT CXR please, eval fot ptx, line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman S/P pancreatic debridement. S/P right IJ\n central line placement.\n\n AP semiupright single view of the chest is compared to .\n\n FINDINGS: There is a right IJ central line with the tip in the cavoatrial\n junction. There is no evidence of pneumothorax. There is again noted a left-\n sided PICC line with the tip in the mid-SVC in unchanged position. There is\n an ET tube located approximately 3 cm from the carina. The cardiomediastinal\n and hilar contours are unchanged in appearance. There are low lung volumes\n when compared to the previous study. In the interval, there is decrease in\n the left pleural effusion. There is minimal residual blunting of the left\n costophrenic angle that may represent small residual pleural effusion. It\n could be loculated. There are degenerative changes of the thoracic spine.\n\n IMPRESSION:\n 1) Interval placement of a right IJ central line with the tip in the\n cavoatrial junction. There is no evidence of pneumothorax.\n 2) Interval decrease in the left pleural effusion.\n\n\n\n" }, { "category": "ECG", "chartdate": "2169-07-02 00:00:00.000", "description": "Report", "row_id": 187075, "text": "Baseline artifact in lead V6. Sinus rhythm. Left atrial abnormality.\nAnterolateral ST-T wave abnormalities - cannot exclude ischemia. Clinical\ncorrelation is suggested. Since the previous tracing of anterolateral\nST-T wave changes are present.\n\n" }, { "category": "ECG", "chartdate": "2169-06-19 00:00:00.000", "description": "Report", "row_id": 187338, "text": "Sinus rhythm. Significant Q waves in lead III with ST segment elevation in\nlead III. ST segment elevation also present in leads II and aVF. Absence of\nST segment depression in lead aVL. INT: POssible inferior pathology which does\nnot fulfill electrocardiographic diagnostic criteria for transmural inferior\nmyocardial infarction. ST segment elevations inferiorly of uncertain\nsignificance. Left atrial abnormality. Compared to the previous tracing\nof ventricular ectopy is no longer present. Minimal ST segment\nelevations were previously present in leads III and aVF. T waves are currently\nflat in lead aVL whereas they were previously upright and normal.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2150-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948594, "text": " 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for pneumothorax, size of effusion\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with metastatic ovarian cancer, now s/ \n REASON FOR THIS EXAMINATION:\n Please eval for pneumothorax, size of effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old female with metastatic ovarian cancer status post\n thoracentesis. No localizing history was provided.\n\n Comparison is made to prior radiograph dated , and prior CT\n dated .\n\n SINGLE ERECT AP PORTABLE CHEST RADIOGRAPH.\n\n Overall appearance of radiographic is unchanged with no significant change in\n size of bilateral pleural effusions (left greater than right) with loculated\n components. Overall, lung volumes remain low and there is a combination of\n atelectasis in both the right and left lower lobes. Multifocal opacities\n within the right lobe are better appreciated on recent CT examination. There\n is no evidence of pneumothorax and cardiomediastinal silhouette and hilar\n contours are stable in appearance. A right-sided PICC catheter is again\n identified with its tip in the mid-SVC.\n\n IMPRESSION:\n\n Grossly unchanged chest radiograph. No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948886, "text": " 5:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change.\n Admitting Diagnosis: PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with bilat pleural effusions.\n REASON FOR THIS EXAMINATION:\n please assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST RADIOGRAPH\n\n INDICATION: 57-year-old woman with bilateral pleural effusions.\n\n COMPARISON: Series of radiographs, most recent dated .\n\n AP BEDSIDE CHEST RADIOGRAPH: Study is limited by patient motion. Overall,\n lung volumes remain low. Bilateral pleural effusions are not overtly changed\n in size. Bibasilar opacities in the right and left lower lobes likely\n represent atelectasis. Cardiomediastinal silhouette is stable in appearance.\n A right-sided PICC is again noted with its tip in mid SVC.\n\n IMPRESSION: Probably no overt change in size of bilateral partially loculated\n pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 948550, "text": " 7:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: low sats\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with sob ovarian ca\n REASON FOR THIS EXAMINATION:\n low sats\n ______________________________________________________________________________\n WET READ: WWM TUE 7:25 PM\n stable c/w torso ct ; bilat pl eff l>>>r, left eff has large loculations\n and intrafissural components\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT HOURS.\n\n HISTORY: Shortness of breath and ovarian cancer.\n\n COMPARISON: CT of the torso .\n\n FINDINGS: Again noted is a large loculated left effusion with a large\n fissural component. A smaller right pleural effusion with associated\n atelectasis is evident as well. As best can be compared between modalities,\n there is little interval change. Volumes are markedly diminished. The\n mediastinum is difficult to assess but is grossly stable. There is no\n pneumothorax.\n\n IMPRESSION: As best can be compared across modalities, there is a markedly\n stable radiograph with bilateral pleural effusions, left much greater than\n right. The left effusion has loculated components with a large intrafissural\n subcomponent as well.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-03-24 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 948562, "text": " 8:34 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: SOB, CXR unchaged, Hypoxia--eval for PE\n Field of view: 36 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with\n REASON FOR THIS EXAMINATION:\n SOB, CXR unchaged, Hypoxia--eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ACKe TUE 9:34 PM\n no p.e.\n worsening bilateral pleural effusions; right is extensively loculated\n worsening of metastatic disease in lungs\n details in dictation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of ovarian cancer, now with shortness of breath.\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images from the thoracic\n inlet to the lung bases before and after uneventful administration of Optiray\n IV contrast, with multiplanar reformats. This study was compared with , .\n\n CT ANGIO CHEST: No pulmonary embolism. No aortic dissection. The aorta is\n normal in caliber, though slightly tortuous. Small pericardial fluid\n collection is slightly worse than the last exam.\n\n CT CHEST BEFORE AND AFTER IV CONTRAST: Large loculated left pleural effusion\n is worse in the interval. The right pleural effusion is also increased. Total\n right lower lobe consolidation is seen with fluid filling the bronchi.\n Multiple pulmonary nodules are again identified, worse in the interval. A\n dominant nodule in the right upper lobe still measures 2.5 x 2.8 cm and ill-\n defined triangular opacity occupying much of the right middle lobe,\n approximately 59 x 60 mm, suggesting a component of consolidation as well as\n metastatic disease. The narrowing of the bronchus intermedius is again\n identified, with an air fluid level. The bronchi to the left lower lobe are\n narrowed in distal segmental and subsegmental regions. A small amount of\n pericardial fluid is seen anterior to the left ventricular wall, slightly\n worse in the interim (10 mm in greatest axial dimension, previously 6 mm).\n\n Several large lymph nodes are seen in the mediastinum, hila, and axillae, e.g.\n an enhancing left axillary node measuring 17 x 30 mm, and an enhancing\n subcarinal node measuring 22 x 11 mm, unchanged.\n\n BONE WINDOWS: Sclerotic lesions are seen in several vertebral bodies, the\n largest in T10 vertebral body and in the sternum, similar to the previous\n exam. No pathologic fractures are identified.\n\n Multiplanar reformats were essential in delineating the findings above.\n\n IMPRESSION:\n (Over)\n\n 8:34 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: SOB, CXR unchaged, Hypoxia--eval for PE\n Field of view: 36 Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No pulmonary embolism. No aortic dissection.\n 2. Interval worsening of large left loculated pleural effusion and small\n right pleural effusion.\n 3. Similar appearance of right lower lobe total consolidation due to\n aspiration.\n 4. Interval slight worsening of thoracic metastatic disease.\n\n Preliminary findings were discussed with Dr. in person at the time\n of interpretation.\n\n" }, { "category": "Echo", "chartdate": "2150-03-25 00:00:00.000", "description": "Report", "row_id": 75473, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 65\nWeight (lb): 163\nBSA (m2): 1.82 m2\nBP (mm Hg): 115/76\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The aortic root is mildly dilated at the sinus level. The\nascending aorta is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. The pulmonary artery systolic pressure could not be determined.\nThere is no pericardial effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-03-27 00:00:00.000", "description": "Report", "row_id": 1387958, "text": " nsg note: 19:00-7:00\nthis is a 67 y.o. woman adm with ovarian ca with mets not responding to any treatments with inc. sob/dyspnea. chest ct negative for pe, but found to have worsening effusion on r with worsening dz process in lungs. pt is DNR/DNI and the palliative RN talked to husband yesterday and discussed the issue of home hospice. The plan for today was for the husband to discuss the issue with the pt and be transferred from ICU to home under hospice care. Overnight, pt required more 02 with desats to 80s and continues to require morphine and ativan for worsening sob/anxiety. Husband informed by micu intern at 6am re: pt's worsening resp status and husband to come in to see pt soon this am.\n\nneuro: pt lethargic, a&ox3, arouses to voice. following commands. able to get oob to commode and back with 1-2 assist early in the eve, but by the end of the shift sob worsening with bedrest maintained for .\n\ncv: hr ranging 120s-130s st with no ectopy noted. bp ranging 120s-130s/60s-70s. +pp.\n\nresp: lungs coarse t/o. sp02 low 90s at beginning of shift on 95% cool neb with 2lnc. By the end of the shift, nc up to 6liters with sat 87%. rapid desat with activity. now desating even at rest and with morphine given for sob. also given ativan for anxiety in the early part of shift. continues with tacypnea to the 30s when sob, down to the 20s after morphine given for sob with good effect per pt.\n\ngi: abd soft, hypoactive bs. no po intake overnight. no bm.\n\ngu: voided 200cc on commode until 11pm. foley placed by 5am for no further void and d/t inc. sob, tacycardia to 130s and desat to 80s. output 185cc.\n\nid: remains on iv levoflox.\n\naccess: r ant poc patent. lla #22g patent.\n\nplan: husband to visit this am and speak to wife re: measures. provide morphine prn for pain/sob and ativan prn anxiety.\n" }, { "category": "Nursing/other", "chartdate": "2150-03-26 00:00:00.000", "description": "Report", "row_id": 1387954, "text": "assessment as noted in carevue\n\nres: dim ls, on face tent 75% coolmist maintains sat>94, strong prod cough\n\ncv: remains in S.tach, bp stable, some edema legs/arms, +pulses\n\nneuro: intact, weak, ambulates to commode well, slept most of the night\n\ngi: npo overnight, has frequent dry heeves, was given emzamet and ativan during the night, vomited once\n\ngu: on commode voids\n\nsocial: famuly was in last night to visit\n\nplan: ? pleural cath insertion to drain pleural effusion, comfort and care\n\n\n" }, { "category": "Nursing/other", "chartdate": "2150-03-27 00:00:00.000", "description": "Report", "row_id": 1387959, "text": "PT. PLACED ON A MORPHINE GTT THIS AM AND GRADUALLY INCREASED FOR RESP DISTRESS TO 3MG/HR. PT. REMAINED COMFORTABLE. MONITOR OFF PER REQUEST FROM FAMILY. FAMILY AND MINISTER BY HER BEDSIDE WHEN SHE EXPIRED. PT. EXPIRED AT 15:20PM. SOCIAL WORKER WAS AVAILABLE TO THE FAMILY AT THE TIME OF DEATH.\nAWAITING SON WHO IS ARRIVING FROM D.C. THIS PM.\n" }, { "category": "Nursing/other", "chartdate": "2150-03-26 00:00:00.000", "description": "Report", "row_id": 1387955, "text": "RESP: BS'S INSP/EXP WHEEZES. TACHPNEIC IN 30'S. HI-FLOW AND NP WHEN OFF MASK. SATS 94-98%. PT. STATES AT TIMES THAT SHE FEELS SOB, WHICH IMPROVES WITH REPOSITIONING.\nGI: NPO ADVANCED TO HOUSE. PT. HAVING DRY HEAVES D/T BEING NPO. ATE SMALL AMT OF PINEAPPLE AND TOAST AND ABLE TO TAKE HER PILLS. GIVEN COMPAZINE AND ATIVAN WITH SOME RELIEF. HYPOACTIVE BS'S. NO BM.\nRENAL: UP TO COMMODE TO URINATE.\nNEURO: ALERT AND ORIENTATED. VERY WEAK.\nID: REMAINS ON ANTIBIOTICS.\nCV: TACHY IN 110'S-120'S, OTHERWISE HEMODYNAMICALLY STABLE.\nSOCIAL: FAMILY IN WITH PT. MOST OF THE DAY. FAMILY MEETING WITH DR. WITH AN AGREEMENT FOR PALLIATIVE CARE. STATED SHE WOULD BE DOWN BETWEEN 4-5PM.\nACCESS: PORTACATH. DRSG .\n" }, { "category": "Nursing/other", "chartdate": "2150-03-26 00:00:00.000", "description": "Report", "row_id": 1387956, "text": "NPN Addendum 1500-1900:\nPt is alert, oriented x3, moving out of bed to commode, breathing with labor on cool nebulizer 15 LPM and NC, SPO2 92-98%, desated once to low 80s, recovered with encouraging deep breathing and re-positioning, felt a mild SOB, CXR taken to check for fluids in lungs, result pending, voiding in commode adequate U/O, no BM this shift, on colace and senna. Pt is /DNR, the palliative nurse talked to husband and discussed the issue of home hospice; the husband was receptive and the plan is to discuss the issue with the patient to be transferred from ICU to home under hospice care?.\n" }, { "category": "Nursing/other", "chartdate": "2150-03-27 00:00:00.000", "description": "Report", "row_id": 1387957, "text": "Resp Care: pt continues with tachycardia/tachypnea with marginal spo2 on hfn .95/nasal 02 5lpm, rapid desat with exercise; bs coarse bilat, no neb rx this shift per pt, will cont comfort care as tol.\n" }, { "category": "Nursing/other", "chartdate": "2150-03-25 00:00:00.000", "description": "Report", "row_id": 1387952, "text": "Nursing Assessment Note 0130-0700\nPt is lovely 57 year old woman with H/O relapsed stage IIC, Grade II papillary serous ovarian ca with seminoma bodies, pt has been on several different regimes of chemo without success, so it was decided that pt would undergo a Phase I clinical Trial of , pt had received 2nd dose on and presented to EW last evening with C/O SOB and dyspnea, Chest CT scan was negative for PE, but did find worsening effusion on right with worsening disease progression, Pt was initially 74% on R/A and then changed to 100% NRB, but was able to wean to 60% mist mask in EW, pt started on 60% but quickly titrated up to 95% High flow O2 to keep sats 90%\n\nNEURO: Pt A&O x3, very pleasant, lovely woman, Pt moves all extremities and ambulates independently with mostly steady gait, we discussed with pt about code status and pt will defer any decision until she can speak with her husband\n\nCV: Pt's vss, afebrile, Pt denied pain, until pt had her effusion tapped, then she c/o pain 3 = 0-10 scale, medicated with tylenol 325 mg po, Pt has right forearm Port-A-cath with NS @ KVO infusing well without problems, Pt also has #22 in left arm, which is patent and intact, Pt in ST without ectopy, skin is pale, warm, and dry, PP + & =, with trace edema\n\nRESP: Pt's lung sounds reveal coarse, but clear sounds in upper lobes and crackles with occasional EXP whez in bases, Pt had thoracentesis on right lung for her worsening effusion, Specimens were sent and pt stated some relief with her breathing after procedure, but is now coughing with more frequency, Pt medicated with robitussin with codeine with fair effect\n\nGI: Pt initially c/o Nausea with dry heaves, pt medicated with anzemet 12.5 mg iv with fair effect, but pt still had some dry heaves, so pt was medicated with 1 mg ativan iv with better effect, pt now able to tolerate po intake without further N/V, bowel sounds are positive, but hypoactive with soft abd\n\nGU: Pt voids clear yellow urine qs\n\nPLAN:\n-Monitor O2 sats and titrate O2 as needed\n-Provide Emotional support for pt and husband\n-?pt to be DNR/DNI\n" }, { "category": "Nursing/other", "chartdate": "2150-03-25 00:00:00.000", "description": "Report", "row_id": 1387953, "text": "NPN M/SICU ICU day 2 (0700 -1900)\n\nEvents: Ecco performed @ bedside this AM, intermittent periods of N/V. No other significant.\n\nReview of Systems:\n\nNeuro: A & O x 3, PEARL, MAE purposefully, able to track and follow commands. C/O pain 7 on 0-10 scale treated Q 4 w/ 4mg Morphine IVP, and Tordol 15mg q 6 w/ good effect.\n\nCV: ST w/ no appreciable ventricular ectopy, NBP 130's systolic, Afebrile. refer to flow sheet for objective data.\n\nResp: S/P R effusion tap (in ) 500cc drained, site of effusion tap is the source of pts pain. LS Coarse upper lobes, occasional crackles lower lobes. Pox 90-95% on 75% humidified face tent. Pt desats to high 70's w/o O2.\n\nGU/GI: Abd soft NT/ND to palpation, Metestatic Mass palpable 5cm to R of umbillicus. BS present, currently on house diet, NPO aftermidnight for placement of pleurex cath tomorrow. Voids clear yellow, able to ambulate to commode.\n\nAccess: Port a cath R forearm, 20 G L AC\n\nPlan: Cont to monitor/maintain heme/resp status, attempt to wean off O2, Pain management q 4. Pleurex cath to be placed @ bedside by IP tomorrow during day shift. Update pt and family on POC as it develops.,\n" }, { "category": "ECG", "chartdate": "2150-03-24 00:00:00.000", "description": "Report", "row_id": 195742, "text": "Sinus tachycardia\nIndeterminate frontal QRS axis\nLow voltage\nLow R(V2-V4) probably due to right ventricular hypertrophy\nSince previous tracing, heart rate increased\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2150-03-23 00:00:00.000", "description": "Report", "row_id": 195743, "text": "Sinus tachycardia. late precordial QRS transition is non-specific. Low\nQRS voltage. Clinical correlation is suggested. Since the previous tracing\nof sinus tachycardia rate is faster.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2177-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140744, "text": " 5:07 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess interval changes\n Admitting Diagnosis: HEMOTHORAX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with L lung mass s/p thoracenetesis\n REASON FOR THIS EXAMINATION:\n assess interval changes\n ______________________________________________________________________________\n WET READ: JXKc MON 7:51 PM\n New air-fluid level in upper left hemithorax, with absent lung markings\n peripherally in the apex, likely reflects a hydropneumothorax. Persistent\n opacification of the left lung.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:23 P.M. ON \n\n HISTORY: Left lung mass following thoracentesis.\n\n IMPRESSION:\n AP chest compared to :\n\n More than half the volume of fluid loculated in the left apical\n hydropneumothorax has been evacuated. Moderate dependent effusion is\n unchanged as is severe leftward mediastinal shift and heterogeneous\n opacification of the small region of aerated left lung. Configuration of the\n left bronchial tree suggests extensive obstruction, predominantly extrinsic.\n Right lung is grossly clear. The heart is not enlarged. Fullness in the\n right lower paratracheal region could be due to adenopathy.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140769, "text": " 10:45 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Any worsening of hydropneumothorax?\n Admitting Diagnosis: HEMOTHORAX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with hydropneumothorax post thoracentesis earlier today,\n feeling more dyspnea.\n REASON FOR THIS EXAMINATION:\n Any worsening of hydropneumothorax?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:02 P.M.\n\n HISTORY: Hydropneumothorax following thoracentesis. More dyspnea. Any\n worsening.\n\n IMPRESSION: AP chest compared to 5:23 p.m. on :\n\n The large loculated left hydropneumothorax and moderate dependent left pleural\n effusion are unchanged. Heterogeneous opacification in the small region of\n aerated left lung has improved, reflecting some clearing of edema, likely\n small nodules and coarse reticulation suggest tumor involvement of the\n pulmonary lymphatics. Extent of bronchial obstruction, presumed large left\n hilar mass is best assessed by CT scanning. Right lung is grossly clear.\n Mild leftward mediastinal shift has improved since 3:17 p.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-07-01 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1140839, "text": " 10:21 AM\n CT CHEST W/CONTRAST Clip # \n Reason: Assess pleural effusion.\n Admitting Diagnosis: HEMOTHORAX\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with pleural effusion.\n REASON FOR THIS EXAMINATION:\n Assess pleural effusion.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT, \n\n HISTORY: A 57-year-old woman with pleural effusion.\n\n TECHNIQUE: Multidetector helical scanning of the chest was coordinated with\n intravenous infusion of 75 mL Optiray nonionic iodinated contrast \n reconstructed as contiguous 5- and 1.25-mm thick axial and 5-mm thick coronal\n and paramedian sagittal images, read in conjunction with the conventional\n chest radiographs of today and yesterday.\n\n FINDINGS: A huge tumor has replaced all of the left upper lobe, contiguous\n with adenopathy or tumor spreading into the left hilus, obstructing the\n superior division of the left upper lobe bronchus proximally, and the lingula\n distally, the branches of the pulmonary artery to the left upper lobe, and\n seriously narrowing the descending pulmonary artery, encasing but not\n occluding the superior segmental bronchus to the left lower lobe. The tumor\n extends into the mediastinum along the right pulmonary artery to a large nodal\n mass in the subcarinal station and superiorly and medially into the\n prevascular space and aortopulmonic window, as far as the sternomanubrial\n joint. Contralateral adenopathy in the mediastinum is present at the right\n upper and lower paratracheal stations, narrowing but not occluding the\n superior vena cava, and not impinging on either the right pulmonary artery or\n right bronchial tree.\n\n A large, thick walled, air and fluid collection at the apex of the left\n hemithorax is either a large, cavitated lung mass or hyropneumothorax. The\n same can be said for two smaller left paraaortic collections of fluid\n surrounded by thickened tissue. A small dependent left pleural effusion\n layers posteriorly. Extensive interstitial tumor infiltration extends from\n the left hilus into the lower lobe. Emphysema in the right lung is severe; a\n 5-mm subpleural nodule in the lower lobe, 3:50, is a likely metastasis.\n\n There are multiple lytic lesions throughout the thoracic and lumbar spine, the\n only one threatening the vertebral canal is in the L1 vertebral body, 4:211.\n\n This study is not designed for subdiaphragmatic evaluation and does not image\n the entire adrenal glands. If there is any reason to stage this lesion below\n the diaphragm, dedicated abdominal imaging would be required.\n\n IMPRESSION:\n (Over)\n\n 10:21 AM\n CT CHEST W/CONTRAST Clip # \n Reason: Assess pleural effusion.\n Admitting Diagnosis: HEMOTHORAX\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Extensive bronchogenic carcinoma involving all of the left upper lobe with\n bronchial and vascular occlusion at the left hilus, contiguous spread across\n the midline into the subcarinal and prevascular mediastinum, as well as the\n contralateral paratracheal station. Large abscessing left upper lobe mass or\n malignant or infectious pleural phlegmon. Multiple osseous metastases\n throughout the thoracic and lumbar spine, one of which may broach the\n posterior cortex of the L1 vertebral body.\n 2. Severe emphysema.\n\n" }, { "category": "Radiology", "chartdate": "2177-07-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1141019, "text": " 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ICU interval change\n Admitting Diagnosis: HEMOTHORAX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with dyspnea.\n REASON FOR THIS EXAMINATION:\n ICU interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:16 A.M. :\n\n HISTORY: Dyspnea. Question interval change.\n\n IMPRESSION: AP chest compared to and :\n\n The large air and fluid collection at the apex of the left chest and the\n moderate dependent pleural effusion are unchanged. Leftward mediastinal shift\n is more severe and greater opacification in the small region of aerated left\n lung both suggests worsening atelectasis. There is a large .\n Emphysema is responsible for hyperlucency of the right lung, but there is no\n focal pulmonary abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1140719, "text": " 3:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with report of ptx now w/ hypoxia, left OSH AMA\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n WET READ: MLHh MON 5:01 PM\n Near-complete opacification of L hemithorax, concerning for drowned lung\n (collapse + edema). Lingular consolidation with residual aeration.\n WET READ VERSION #1 MLHh MON 4:41 PM\n Near-complete opacification of L hemithorax, concerning for drowned lung\n (collapse + effusion). Lingular consolidation with residual aeration.\n WET READ VERSION #2 MLHh MON 5:01 PM\n Near-complete opacification of L hemithorax, concerning for drowned lung\n (collapse + edema). Lingular consolidation with residual aeration.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old female with reported pneumothorax at outside\n hospital, hypoxia.\n\n No prior examinations for comparison.\n\n CHEST, AP UPRIGHT: There is near-complete opacification of the left\n hemithorax, with ipsilateral mediastinal shift and elevation of the left\n hemidiaphragm. This appearance may be seen with lung collapse, although\n components of pulmonary edema, consolidation, and loculated effusion cannot be\n excluded. The left upper and lower lobes are involved, with some residual\n aeration in the lingula. There is some narrowing of the left main stem\n bronchus, without definite cut-off. The right lung is clear.\n\n IMPRESSION: Findings concerning for \"drowned\" lung secondary to left lung\n collapse. Necrotizing pneumonia and massive aspiration are additional\n possibilities.\n\n" }, { "category": "ECG", "chartdate": "2177-06-30 00:00:00.000", "description": "Report", "row_id": 236547, "text": "Sinus tachycardia. Rightward axis. Prominent precordial lead QRS voltage\nsuggests left ventricular hypertrophy. Modest ST-T wave changes. Unstable\nbaseline makes assessment difficult. Findings are non-specific. No previous\ntracing available for comparison.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2132-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440156, "text": "Mitral regurgitation (Mitral insufficiency)\n Assessment:\n Neuro: A&O x3, MAE and follows commands. C/O moderate pain. HR 80\n apaced overnoc w/ intrinsit hr 70\ns , frequent apc\ns. Hypotensive w/\n slower rate. Low dose neo overnoc. Resp: LS clear, using IS up to\n 1100. Stable 02sats. GI: No difficulty swallowing. No nausea. Renal:\n Stable. Heme: Hct stable. Low CT output.\n ID: Stable. Skin: intact.\n Action:\n Neo gtt overnoc. Increased apacing to 88 and weaning neo. Percocet 2\n tabs q6hrs.\n Response:\n Stable hemodynamics and mproved bp, decreased ectopy w/ apacing.\n Adequate pain control.\n Plan:\n Cont to monitor hemodynamics. Wean neo. Deline. OOB to chair and pulm\n toilet. Ready pt for transfer.\n" }, { "category": "Physician ", "chartdate": "2132-02-19 00:00:00.000", "description": "Intensivist Note", "row_id": 440200, "text": "CVICU\n HPI:\n HD2\n POD1\n 70W s/p septal myomectomy \n EF 55% CR 0.5 WT 74.4K HgA1c 5.8\n PMH: Diverticulitis, HOCM, hypothyroidism, Mitral regurgitation, TIA\n after cath, hysterectomy\n : Toprol XL 50\", Verapamil 240', Pravastatin 40', Synthroid 50',\n Fish oil, Calcium 600\", MVI\n 24hr events: extubated\n Chief complaint:\n PMHx:\n Current medications:\n 1. 2. 250 mL D5W 3. Acetaminophen 4. Aspirin EC 5. Calcium Gluconate 6.\n CefazoLIN 7. Dextrose 50%\n 8. Docusate Sodium 9. Insulin 10. Influenza Virus Vaccine 11. Magnesium\n Sulfate 12. Metoclopramide\n 13. Milk of Magnesia 14. Morphine Sulfate 15. Nitroglycerin 16.\n Oxycodone-Acetaminophen 17. Phenylephrine\n 18. Pneumococcal Vac Polyvalent 19. Potassium Chloride 20. Ranitidine\n 21. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n OR RECEIVED - At 11:14 AM\n INVASIVE VENTILATION - START 11:16 AM\n ARTERIAL LINE - START 11:51 AM\n CORDIS/INTRODUCER - START 11:52 AM\n PA CATHETER - START 12:00 PM\n NASAL SWAB - At 12:02 PM\n EKG - At 01:30 PM\n EXTUBATION - At 04:40 PM\n Okay to extubate per Mark CourtneyNP\n INVASIVE VENTILATION - STOP 04:40 PM\n Post operative day:\n POD#1 - Septal Myomectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 07:13 PM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 04:34 PM\n Morphine Sulfate - 09:00 AM\n Other medications:\n Flowsheet Data as of 11:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.6\nC (99.7\n HR: 88 (63 - 88) bpm\n BP: 97/49(65) {90/49(65) - 150/76(101)} mmHg\n RR: 12 (7 - 20) insp/min\n SPO2: 97%\n Heart rhythm: A Paced\n Height: 67 Inch\n CVP: 9 (4 - 19) mmHg\n PAP: (25 mmHg) / (13 mmHg)\n CO/CI (Thermodilution): (3.78 L/min) / (2 L/min/m2)\n CO/CI (Fick): (4.9 L/min) / (2.7 L/min/m2)\n SVR: 1,228 dynes*sec/cm5\n SvO2: 61%\n Mixed Venous O2% sat: 63 - 66\n SV: 43 mL\n SVI: 23 mL/m2\n Total In:\n 7,666 mL\n 702 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,166 mL\n 702 mL\n Blood products:\n 500 mL\n Total out:\n 4,605 mL\n 560 mL\n Urine:\n 3,415 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,061 mL\n 142 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 445 (445 - 445) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SPO2: 97%\n ABG: 7.38/43/111/24/0\n Ve: 5.8 L/min\n PaO2 / FiO2: 222\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 169 K/uL\n 10.0 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.6 mEq/L\n 8 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.7 %\n 13.4 K/uL\n [image002.jpg]\n 04:08 PM\n 04:30 PM\n 05:30 PM\n 06:30 PM\n 07:30 PM\n 07:31 PM\n 08:30 PM\n 10:00 PM\n 02:12 AM\n 02:35 AM\n WBC\n 13.4\n Hct\n 28.1\n 28.7\n Plt\n 169\n Creatinine\n 0.7\n TCO2\n 26\n 26\n Glucose\n 162\n 133\n 111\n 133\n 111\n 102\n 138\n 135\n Other labs: PT / PTT / INR:14.7/38.9/1.3, Fibrinogen:215 mg/dL, Lactic\n Acid:1.2 mmol/L, Mg:2.1 mg/dL\n Assessment and Plan\n OBESITY (INCLUDING OVERWEIGHT, MORBID OBESITY), .H/O DIVERTICULITIS,\n HYPERGLYCEMIA, MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Alert, Awake\n Cardiovascular: Aspirin, Beta-blocker, Hemodynamically stable, add Beta\n blocker\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Lasix for Duresis\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:51 AM\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2132-02-19 00:00:00.000", "description": "ICU Note - CVI", "row_id": 440201, "text": "CVICU\n HPI:\n Printing Cardiac for , TUE 11:53 AM\n _______________________________________________________________________\n _________________________\n Name DOB Age Admit Attending\n , CC7B-0774-01 70 \n , R.\n Allergies: NKDA\n Resident: , M.\n Last Updated by , on @ 2032 Patient location\n when updated: CC7B-0774-01\n HD2\n POD1\n 70W s/p septal myomectomy \n EF 55% CR 0.5 WT 74.4K HgA1c 5.8\n 24hr events: extubated\n Chief complaint:\n PMHx:\n PMH: Diverticulitis, HOCM, hypothyroidism, Mitral regurgitation, TIA\n after cath, hysterectomy\n : Toprol XL 50\", Verapamil 240', Pravastatin 40', Synthroid 50',\n Fish oil, Calcium 600\", MVI\n Current medications:\n Active Medications ,\n 1. 2. 250 mL D5W 3. Acetaminophen 4. Aspirin EC 5. Calcium Gluconate 6.\n CefazoLIN 7. Dextrose 50%\n 8. Docusate Sodium 9. Insulin 10. Influenza Virus Vaccine 11. Magnesium\n Sulfate 12. Metoclopramide\n 13. Milk of Magnesia 14. Morphine Sulfate 15. Nitroglycerin 16.\n Oxycodone-Acetaminophen 17. Phenylephrine\n 18. Pneumococcal Vac Polyvalent 19. Potassium Chloride 20. Ranitidine\n 21. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n OR RECEIVED - At 11:14 AM\n INVASIVE VENTILATION - START 11:16 AM\n ARTERIAL LINE - START 11:51 AM\n CORDIS/INTRODUCER - START 11:52 AM\n PA CATHETER - START 12:00 PM\n NASAL SWAB - At 12:02 PM\n EKG - At 01:30 PM\n EXTUBATION - At 04:40 PM\n Okay to extubate per CourtneyNP\n INVASIVE VENTILATION - STOP 04:40 PM\n Post operative day:\n POD#1 - Septal Myomectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 07:13 PM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 04:34 PM\n Morphine Sulfate - 09:00 AM\n Other medications:\n Flowsheet Data as of 11:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.6\nC (99.7\n HR: 88 (63 - 88) bpm\n BP: 97/49(65) {90/49(65) - 150/76(101)} mmHg\n RR: 12 (7 - 20) insp/min\n SPO2: 97%\n Heart rhythm: A Paced\n Height: 67 Inch\n CVP: 9 (4 - 19) mmHg\n PAP: (25 mmHg) / (13 mmHg)\n CO/CI (Thermodilution): (3.78 L/min) / (2 L/min/m2)\n CO/CI (Fick): (4.9 L/min) / (2.7 L/min/m2)\n SVR: 1,460 dynes*sec/cm5\n SvO2: 61%\n Mixed Venous O2% sat: 63 - 66\n SV: 43 mL\n SVI: 23 mL/m2\n Total In:\n 7,666 mL\n 703 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,166 mL\n 703 mL\n Blood products:\n 500 mL\n Total out:\n 4,605 mL\n 560 mL\n Urine:\n 3,415 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,061 mL\n 143 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 445 (445 - 445) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SPO2: 97%\n ABG: 7.38/43/111/24/0\n Ve: 5.8 L/min\n PaO2 / FiO2: 222\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 169 K/uL\n 10.0 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.6 mEq/L\n 8 mg/dL\n 105 mEq/L\n 134 mEq/L\n 28.7 %\n 13.4 K/uL\n [image002.jpg]\n 04:08 PM\n 04:30 PM\n 05:30 PM\n 06:30 PM\n 07:30 PM\n 07:31 PM\n 08:30 PM\n 10:00 PM\n 02:12 AM\n 02:35 AM\n WBC\n 13.4\n Hct\n 28.1\n 28.7\n Plt\n 169\n Creatinine\n 0.7\n TCO2\n 26\n 26\n Glucose\n 162\n 133\n 111\n 133\n 111\n 102\n 138\n 135\n Other labs: PT / PTT / INR:14.7/38.9/1.3, Fibrinogen:215 mg/dL, Lactic\n Acid:1.2 mmol/L, Mg:2.1 mg/dL\n Assessment and Plan\n OBESITY (INCLUDING OVERWEIGHT, MORBID OBESITY), .H/O DIVERTICULITIS,\n HYPERGLYCEMIA, MITRAL REGURGITATION (MITRAL INSUFFICIENCY)\n Assessment and Plan: 70yoW s/p myomectomy. Hemodynamically stable\n Neurologic: Pain controlled, Morphine and percocet\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, OOB-ambulate.\n CXR with left sided effusion\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, start lasix for diuresis-goal net negative 1-1.5 liters\n Hematology: stable hct\n Endocrine: RISS, synthroid\n Infectious Disease: no active issues-afebrile\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, after CT removal\n Fluids: KVO\n Consults: CT surgery, P.T.\n ICU Care\n Nutrition: ADAT\n Glycemic Control:\n Lines:\n Arterial Line - 11:51 AM\n 20 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2132-02-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440206, "text": "Pt. POD 1 s/p septal myomectomy. Pt. AP at 88 overnight for BP\n support, also Pt. on neo gtt overnight, weaned off this a.m. without\n incident. Pt. stable.\n H/O Mitral regurgitation (Mitral insufficiency) s/p Septal Myomectomy\n Assessment:\n VSS with MAPS>60 off neo. Skin warm, dry, color slightly pale.\n Surgical inc\ns with dry dressings. LS clear, no pulmonary complaints.\n Abd. Benign. UO adequate. Pt. presently sitting up in chair.\n Action:\n Neo weaned to off this a.m. PAC, cordis removed without incident.\n Apacer decreased to AAI @60. 2 med\ns CT\ns removed by HO this\n afternoon. Pain treated this a.m. with morphine (not due for Percocet\n at the time.)\n Response:\n Pt. in SR 70\ns. MAP 60 sitting up in chair (90\ns/50). No complaints.\n Plan:\n Transfer to 6 per cardiac surgical pathway.\n" }, { "category": "Nursing", "chartdate": "2132-02-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440211, "text": "Pt. POD 1 s/p septal myomectomy. Pt. AP at 88 overnight for BP\n support, also Pt. on neo gtt overnight, weaned off this a.m. without\n incident. Pt. stable, ready for transfer.\n H/O Mitral regurgitation (Mitral insufficiency) s/p Septal Myomectomy\n Assessment:\n VSS with MAPS>60 off neo. Skin warm, dry, color slightly pale.\n Surgical inc\ns with dry dressings. LS clear, no pulmonary\n complaints. Abd. Benign. UO adequate. Pt. presently sitting up in\n chair.\n Action:\n Neo weaned to off this a.m. PAC, cordis removed without incident.\n Apacer decreased to AAI @60. 2 med\ns CT\ns removed by HO this\n afternoon. Pain treated this a.m. with morphine (not due for Percocet\n at the time.)\n Response:\n Pt. in SR 70\ns. MAP 60 sitting up in chair (90\ns/50). No complaints.\n CXR stable.\n Plan:\n Transfer to 6 per cardiac surgical pathway.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n MITRAL INSUFFICIENCY MITRAL VALVE REPLACEMENT / MYOMECTOMY/\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 74.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: CAD, Hypertension\n Additional history: H/o C diff , diverticulitis, hypertrophic\n obstructive cardiomyopathy, hypothyroidsism, HTN, TIA\n (aphasia-resolved) after catheterization , hypercholesterolemia,\n hysterectomy.\n Married. Lives in . Pt's daughter works at /trauma SICU.\n Surgery / Procedure and date: Septal Myomectomy. Crystal 3L, 300cc\n CS, Urine 1000cc. Kefzol given in OR. prior to case and on arrival to\n CVICU (ivp by M.D.)\n CPB 55\", XCP 35\". AVP->AP. Normal biventricular systolic fx. Opening PA\n ~20/10. Insulin in divided doses 15u for peak glucose 173.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:45\n Temperature:\n 99.68 F\n Arterial BP:\n S:95\n D:45\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97%\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.4 mV\n Temporary atrial sensitivity setting:\n 0.7 mV\n Temporary atrial stimulation threshold :\n 10 mA\n Temporary atrial stimulation setting:\n 14 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 4 mV\n Temporary ventricular stimulation threshold :\n 8 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Permanent pacemaker mode:\n Atrial demand\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 02:12 AM\n Potassium:\n 4.6 mEq/L\n 02:12 AM\n Chloride:\n 105 mEq/L\n 02:12 AM\n CO2:\n 24 mEq/L\n 02:12 AM\n BUN:\n 8 mg/dL\n 02:12 AM\n Creatinine:\n 0.7 mg/dL\n 02:12 AM\n Glucose:\n 135 mg/dL\n 02:35 AM\n Hematocrit:\n 28.7 %\n 02:12 AM\n Finger Stick Glucose:\n 138\n 12:00 PM\n Valuables / Signature\n Patient valuables: Dentures: (Upper, Lower )\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2132-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440042, "text": " Septal Myomectomy. Crystal 3L, 300cc CS, Urine 1000cc. Kefzol given\n in OR. prior to case and on arrival to CVICU (ivp by M.D.)\n CPB 55\", XCP 35\". AVP->AP. Normal biventricular systolic fx. Opening PA\n ~20/10. Insulin in divided doses 15u for peak glucose 173. EZ\n intubation.\n Mitral regurgitation (Mitral insufficiency)\n Assessment:\n Pt admitted from the O.R. s/p\nSeptal Myomectomy\n. Labile SBP\n requiring multiple adjustments of Neosynephrine and 4-5liters LR\n replacement. Periods of ^unifocal PVCs. Serum potassium as low as 3.0.\n early post-op. CI <1.7by TD and 2.9 by Fick. Some TR reported by\n anesthesiologist. NSR in the 70s noted.\n Action:\n Neosynephrine weaned off with improved SBP. A pacing used to help boost\n CO. LR fluid replacement as noted to keep\nfilling pressures high\n requested. Plan to observe CI by TD and note that her CI by FICK is\n better.\n Response:\n CI within goal. SBP within goal 120-130s\n Plan:\n Plan to monitor closely. need additional volume tonight.\n .H/O diverticulitis\n Assessment:\n Pt history includes diverticulitis. Pt reports that she she avoids\npeanuts, seeds, kernels, tree nuts\n which are noted as\nallergies in\n her chart\n Action:\n Pt will continue to avoid items that will give her trouble with her\n divertuculitis.\n Response:\n Unknown\n Plan:\n See above.\n Hyperglycemia\n Assessment:\n Glucose to 160s in CVICU. No history of hyperglycemia.\n Action:\n CVICU insulin guideline in use.\n Response:\n Glucose dropping.\n Plan:\n Continue to follow guidelines to keep glucose <120.\n" }, { "category": "Echo", "chartdate": "2132-02-18 00:00:00.000", "description": "Report", "row_id": 84718, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertrophic cardiomyopathy. Left ventricular function. Mitral valve disease. Preoperative assessment.\nStatus: Inpatient\nDate/Time: at 09:08\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Elongated mitral valve\nleaflets. of mitral valve leaflets. Moderate (2+) MR. to the eccentric\nMR jet, its severity may be underestimated (Coanda effect).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPREBYPASS\nNo atrial septal defect is seen by 2D or color Doppler. Right ventricular\nchamber size and free wall motion are normal. There are simple atheroma in the\ndescending thoracic aorta. The aortic valve leaflets are mildly thickened.\nTrace aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. The mitral valve leaflets are elongated. After induction no was\nvisualized but after reverse Trendelenburg and Valsalva systolic anterior\nmotion of the mitral valve leaflets with at least moderate (2+) posteriorly\ndirected MR in the LVOT is visualized. Due to the eccentric\nnature of the regurgitant jet, its severity may be significantly\nunderestimated (Coanda effect). There is left ventricular hypertrophy. Overall\nbiventricular systolic function is normal\n\nPOST BYPASS\nThere is preserved biventricular systolic function. At rest minimal and MR\nis present immediately post bypass, however and significant MR e by Valsalva. After filling patient with volume to a CVP -14 and PA\n29/14 and MR decreased but was still present. An accurate LVOT gradient\nwas not obtainable.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-02-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1061392, "text": " 11:02 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: MITRAL INSUFFICIENCY\\MITRAL VALVE REPLACEMENT / MYOMECTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p septal myomectomy\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 11:16\n\n INDICATION: Myomectomy and abnormal breath sounds.\n\n COMPARISON: .\n\n FINDINGS:\n Appearance of the bilateral pleural effusions and adjacent atelectatic changes\n do not appear substantially different compared to the prior study. There are\n no new consolidations. -apical pleural scarring is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1060573, "text": " 1:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ptx\n Admitting Diagnosis: MITRAL INSUFFICIENCY\\MITRAL VALVE REPLACEMENT / MYOMECTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p septal myomectomy\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 3:54 PM\n PFI: No pneumothorax or any other complication.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP PORTABLE SINGLE VIEW\n\n INDICATION: Status post septal myomectomy. Evaluate for pneumothorax.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position, and analysis is performed in direct comparison\n with a preceding similar study dated . During the interval,\n the patient has been extubated, the pulmonary catheter including right\n internal jugular sheath have been removed, the same holds for the NG tube and\n the previously present mediastinal drainage tubes. No pneumothorax has\n developed. Heart size is moderately enlarged postoperatively and some cloudy\n densities in the bases suggestive of some postoperative pleural effusions. No\n new parenchymal infiltrates are identified, and no pneumothorax is seen.\n Frontal view is also compared with the preoperative chest examination of\n . It confirms moderate enlargement of heart shadow\n postoperatively and the basal densities, some pleural effusion, and probably\n atelectasis on left base in retrocardiac space. No other new abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1060574, "text": ", R. CSURG CSRU 1:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ptx\n Admitting Diagnosis: MITRAL INSUFFICIENCY\\MITRAL VALVE REPLACEMENT / MYOMECTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p septal myomectomy\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n PFI REPORT\n PFI: No pneumothorax or any other complication.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-02-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1060300, "text": " 10:58 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion\n Admitting Diagnosis: MITRAL INSUFFICIENCY\\MITRAL VALVE REPLACEMENT / MYOMECTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p Septal Myomectomy. Please page at \n with abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:40 A.M. :\n\n HISTORY: Septal myomectomy. Look for complications.\n\n IMPRESSION: AP chest compared to preoperative study on :\n\n Mild widening of the cardiomediastinal silhouette is probably a normal\n postoperative result, particularly with the patient supine, also accounting\n for pulmonary vascular congestion. Pneumomediastinum is clinically\n insignificant. Tip of the Swan-Ganz catheter projects over the main pulmonary\n artery, nasogastric tube ends in the lower esophagus and would need to be\n advanced at least 10 cm to move all the side ports into the stomach. ET tube\n and midline drains are in standard placements. No pneumothorax. \n and I discussed these findings at the time of dictation.\n\n" }, { "category": "ECG", "chartdate": "2132-02-23 00:00:00.000", "description": "Report", "row_id": 226940, "text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2132-02-18 00:00:00.000", "description": "Report", "row_id": 226941, "text": "Normal sinus rhythm. Left bundle-branch block with a QRS duration\nof 140 milliseconds. Axis is minus 45 degrees. Compared to the previous\ntracing of the patient has developed complete left bundle-branch block.\nClinical correlation is suggested. In the presence of an acute coronary\nsyndrome, this may represent a recent myocardial infarction.\n\n" }, { "category": "Radiology", "chartdate": "2132-02-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1060938, "text": " 8:47 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: MITRAL INSUFFICIENCY\\MITRAL VALVE REPLACEMENT / MYOMECTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p septal myomectomy\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: S/P septal myomectomy.\n\n COMPARISON: .\n\n Bilateral pleural effusions are small and associated with adjacent\n atelectasis. Mild cardiomegaly is unchanged. Sternal wires are aligned.\n Biapical pleural scarring in the apices is unchanged.\n\n DR. \n" } ]

[ { "category": "Nursing/other", "chartdate": "2204-07-24 00:00:00.000", "description": "Report", "row_id": 1515695, "text": "MICU A NPN 7p-7a\nPt adm to MICU after c/o bilateral LE pain, treated with morphine in ED. K+ 8.1, BS 550 and Crea 13 upon arrival to ER. Pt was given calcium gluconate, insulin and bicarb, and refused to take kayexylate. Insulin gtt started and PD ordered to be done q2 hrs.\n\nNeuro: Pt awake upon arrival to ICU, was cooperative with care, appeared anxious at times. C/O pain in abdomen and states she has been having that pain for several weeks and has seen MD about it before today. MAE, denies blurred vision, h/a or dizziness. Pt quickly fell asleep after getting settled into room.\n\nCV: HR 70's SR with noted peaked T waves. No ectopy, SBP 150-185, afebrile. Last K down to 6.4, most recent labs still pending. L SC TLC intact. Blood cx x2 sent to lab.\n\nPULM: LS diminished t/o, RR 12-22. O2 sats mostly in high 90's on RA, but one period of desating noted ? if pt was apneic at one point. NC placed and pt pulls it off each time it is replaced.\n\nGI/GU: Abd softly distended, +tenderness. +BS. Insulin gtt infusing per protocol, but currently maxed at 20units/hr. BS checks done on hourly basis at this time. MD aware of high dose of insulin and wants it to stay at 20units/hr for now. Ionized calcium 1.05, pt given cal gluc 2gms ivpb. PD done q2hrs, heparin added to each bag of dialysate per order. F/C not draining over last few hours.\n\nSkin: Skin t/o noted to have several ?statis? ulcers that are open and somewhat scabbed over.\n\nGeneral: No family contact since admission. Pt appears unkempt, feces noted to be on personal belongings. Personal belongings also included pts pocketbook that was locked up in MICU safe by 2 RNs.\n\nCont. to check BS q1hr or as needed, PD q 2 hrs. F/U with pending labs.\n" }, { "category": "Nursing/other", "chartdate": "2204-07-24 00:00:00.000", "description": "Report", "row_id": 1515696, "text": "Micu Nursing Progress Notes\nEvents: Blood sugar very labile, insulin gtt decreased from 20U/hr to 3u/hr. Glargine restarted recommendations. Remains very volume overloaded, PD solution changed to 4.25%. Team meeting, all caring for , set up for 11am tomorrow.\n\n: Initially insulin at 20u/hr however blood sugar started to fall with first finger stick. Rate was decreased over the day to 3u/hr by 1400. Her blood sugars continued to fall despite encouragement for her to eat. She did eat some chicken salad for lunch but her blood sugar was a low at 1500. She was given amp D50, started on D10W at 100cc/hr, and given 10U glargine. Her Blood sugar increased from 166 to 195.\n\nGI: Ate small amount for breakfast before C/O nausea. Ate very little for lunch stating she didn't like anything. Abd distended and firm with positive bowel sounds.\n\nCardiac: B/P 130-160/65-75, HR 66-76. K+ dropping with PD 4.8-5.0.\n\nGU: foley draining 70cc clear yellow urine in 12hr. PD runs done q2h with 100-150cc negative with each run for a total of 400cc, howeve she was (+) 300cc for one run making her only 100cc net neg by 1500. Dr. in and changed the PD solution to 4.25% with exchanges q4h. The first run ended at 1800 with a balance of 500cc negative.\n\nResp: RR 10-18, O2 sats 96-99% on room air. She occasionally has a very junky, bronchitis sounding cough in which her O2 sats improve.\n\nNeuro: Very sleepy today stating she did not get much sleep last night, buy easily . Moving upper extremities easily but her legs she moves with difficulty due to the edema. She has been mostly cooperative but did get very agitated around 1700 when she was incontinent of stool and wanted to be cleaned faster than could be done.\n\nSkin: Legs very edemous and tender. Did C/O pain but no pain meds given due to her somulance. She has numerous ulcers on both lower legs some oozing serous fluid. She also has ulcers on her forearms but these are dry.\n\nSocial: Pt talking to daughter on the phone but has had no contact with medical staff. Plan for medical team meeting tomorrow at 11am, with Dr , MD's, Pshych, social service, and several others that tried to meet prior to her discharge last admission. However she signed out AMA before that meeting took place.\n\nPlan: check labs at 1800 with blood sugar with posible transition off insulin to sliding scale, PD exchanged with 4.25% q4h, team meeting with her medical staff tomorrow at 11am.\n" }, { "category": "Nursing/other", "chartdate": "2204-07-25 00:00:00.000", "description": "Report", "row_id": 1515697, "text": "MICU A NPN 7p-7a\n: Insulin gtt d/c'd after pt rec'd evening lantus dose and acetone level came back negative. BS in 150-225 range prior to discontinuaion. Pt was treated with insulin SC per sliding scale that was written prior to d/c of gtt. Pt has had several snacks since dinner time.\n\nNeuro: Pt a/o x3, able to sleep t/o most of shift. Did c/o pain x2 to bilateral lower extremities, was treated with morphine 2mg ivp both times with good effect. Pt able to turn self in bed, but with difficulty moving lower extemities. Pt has been cooperative with care.\n\nGI/GU: Abd softly distended, +BS. Incontinent of stool x1. Pt has had several small snacks this shift. PD continues on schedule of q4hrs. using 4.25% dextrose soln. Pt has been negative with each exchange this shift, see i/o's for details. F/C draining 0-5cc/hr.\n\nPulm: LS with bibasilar crackles, RR 10-20, O2 sats mostly in high 90's, but occasionally dip to low 90's when sleeping. Pt has nonproductive cough.\n\nCV: HR SR 70's, no ectopy noted. SBP 130-150's, pt rec'd scheduled dose of lopressor.\n\nSkin: Multiple ulcers t/o body, some open and weeping serous fluid, others partly scabbed over with no drainage. All wound areas cleaned with soap and water, left open to air. Sheep skin placed beneath heels.\n\nPlan: COnt PD q4hr, BS checks qAC and medical team meeting today.\n" }, { "category": "Nursing/other", "chartdate": "2204-07-25 00:00:00.000", "description": "Report", "row_id": 1515698, "text": "Micu Nursing Progress Notes\nEvents: PD continues with 4.25% and timing increased to Q3h, blood sugars continue to be high 200-300, team meeting held and will proceed with getting a court appointed guardian.\n\nCardiac: B/P has been 106-133/40-60, HR 72-76.\n\nResp: remains on room air with O2 sats 96-98%, RR 12-18.\n\nGI: continues with poor appetite despite encouragement to eat. At alittle this am then C/O nausea. Took most of her pills but refused to take phoslo until the 6pm dose. No stool today.\n\n: Blood sugars remain high 275-310. She was given 20u glargine and 12u at noon and her blood sugars started to improve- 206-243. She will receive 18u glargine this PM and will return to her baseline 38u glargine tomorrow.\n\nGU: continues on the PD with the 4.25% dialysis solution q4h. With each run she has been 750-950cc negative. So far she is ~3500cc negative since MN. The MD's have increased the timing of her runs to Q3H to help remove more fluid.\n\nNeuro: Pt has been bordeline beligerant, ignoring alot of communication with the medical staff since Dr talked to her after the team meeting. The team agreed that her non-compliance after leaving the hospital is not in her best interest. She neglects herself to near fatality. The process has begun to appoint a legal guardian for her, permission will be obtained for an HD catheter to be placed-something she has resisted in the past, and she will not be allowed to leave the hospital AMA until these issues are resolved. Dr. note stated that she understood this and agreed to with it but she has been very withdrawn most of the day. She did also C/O bilateral leg pain requiring MSO4 2mg IV for relief.\n\nSocial: No contact with the family.\n\nPlan: increase timeing of the PD runs to Q3h, closely monitor her BS, do not allow her to leave- not really an issue at this time due to fact she could not get OOB due to the edema in her legs.\n" }, { "category": "Nursing/other", "chartdate": "2204-07-26 00:00:00.000", "description": "Report", "row_id": 1515699, "text": "MICU A NPN 7p-7a\nNeuro: Pt has been lethargic, sleeping t/o most of shift. When pt awakens, she frequently asks for pain meds. Pt was medicated with Morphine 2mg ivp for c/o bilateral leg pain. Pt has been cooperative with care overnight, weepy at times.\n\nCV: HR 60-80's SR, no ectopy noted. K is <5 this am. SBP 100-150's, pt did receive scheduled dose of lopressor last evening. Tmax 101.1 at 0500, WBC 12.7 today, essentially the same as yesterday.\n\nPulm: LS with bibasilar crackles, pt oxygenating well on RA while awake. O2 sats do dip to low 90's at times while pt sleeps.\n\nGI/GU: Pt had 2 snacks consisting of crackers and milk overnight. Also was incontinent of stool x1. Abd softly distended, +BS. Pt continues on PD q3hrs using 4.25% Dextrose soln. At this point pt is -800cc for the day so far, and approx. -4L since admission. Pt continues to have 3+ edema to lower extrem and 2+ general edema despite fluid removal over past 2 days. F/C draining 0-15cc/hr.\n\n: Remains on sliding scale, covered with insulin as indicated. BS this am 160, which is improved from previous sugars in >200 range. Pt did get scheduled dose of glargine 18units at bedtime. Today pt will return back to baseline glargine dose of 38 units at bedtime.\n\nSocial: No family called or visited.\n\nPlan: Pt ultimately to be placed under legal guardianship over next few days as she is unable to care for self. PD cont q3hr, BS checks qid. Pt has hx of leaving AMA, it has been discussed that if pt attempts to do so, security should be involved and pt should not be allowed to leave.\n" }, { "category": "Nursing/other", "chartdate": "2204-07-26 00:00:00.000", "description": "Report", "row_id": 1515700, "text": "Addendum to above note\nBlood cx x2 sent from central line, pt ordered for chest xray and urine cx as well. Order for Picc line is in the computer from yesterday.\n" }, { "category": "Nursing/other", "chartdate": "2204-07-26 00:00:00.000", "description": "Report", "row_id": 1515701, "text": "NPN 0700-1900\n35 y/o female adm. for c/o bialt. LE pain, found to have K=8.1 and Creatine 13. Tx with Ca gluconate, biacarb and insulin and adm to MICU for freuquent PD. Pt's current problems include IDDM, Chronic renal failure with with a longstanding hx of medical non-compliance(please see adm note for other hx). Currently on q 3hr. PD, dialysate changed today to 2.5% Dextrose Dialysate with units of Heparin per 2.5L bag. Temp up to 100.1 last night, started on Linezolid and Ceftriaxone today. To have midline/?PICC line inserted in IR tomorrow, however currently pt is refusing, HO aware. Also, pt needs placement of HD catheter, however, pt is refusing today although team states that she agreed to have this done yesterday. Out going dialysate fld. collected for culture. Please re-collect urine for cx.\n\nNeuro: Alert and Oriented x 3, follows commands, cooperative, c/o pain to lower back and bilat. feet while awake, given MSO4 2mg IV prn.\n\nResp: Lungs Diminshed bilat., RR 11-24, even and unlabored, no c/o SOB, O2 sats 92-96%.\n\nCV: HR 74-77 NSR, no ectopy, BP's 118-156/50-80, edema to lower extremities appears improved now +1/+1. Pedal Pulse weak but palpable bilat.\n\nGI: Abd. softly distended, bs (+) x 4 quad, c/o abd. pain only on palpation, eating only 10% of meal which was picked-out by her, drank 3 cartons of low fat milk today. PD q 3hrs. next due at 2100.\n\nGU: Foley cath draining minimum amts of urine, please obtain urine cx when available.\n\nSkin: Mult. scab wounds to extremities, pt continuously picking at wound on abd. which is reddish at the center 2cm/2cm in size, tegaderm applied to area to prevent bldg., pt also picking at scab on R FA which has bled x 2 today, gauze applied to site. L heel with sore, pink at the edges, brownish black at the center, sheepskin on bed to avoid irritation, wound cleansed with NS.\n\nSocial: Pt's attorney in today, he spoke with SW and provided information on pt's family which are noted in chart.\n\nPLan: If pt is to try to leave AMA as on past admissions we are to call a code grey as her ability to make decisions is under question, team still to place her under legal guardianship. Continue PD, monitor VS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2204-07-27 00:00:00.000", "description": "Report", "row_id": 1515702, "text": "Pt is refusing to go to IR for placement of permanent HD line. Surgery in to get her consent which she adamantly refused in spite of resident's attempts to persuade her. TLC cath removed and tip cultured. PIV 20G in R forearm.\n\nNeuro: Pt a+o, cooperative at times but also needy and manipulative. MAE, following commands, c/o pain in legs often. Tx with morphine sulfate 2mg q4hrs with relief. 1x dose extra given.\n\nResp: O2 sats in mid to low 90's on room air. Will not keep nasal cannula on. Lung sounds diminished. No c/o sob\n\nCardiac: SR on monitor with no ectopy. Hypertensive much of shift. With systolic b/p's 130's-160's. Continues on po lopressor. NO complaints of chest pain or shortness of breath.\n\nGI: Abd soft/distended, positive bowel sounds, no bm this shift. Had a snack of milk and crackers at 0300.\n\nGU: Pt making scant urine. Approx 8cc/hr. Urine cultured. Peritoneal Dialysis continues with 2.25% Dextrose solution with changes q3hrs. Removing between 500-800cc per pass.\n\nDerm: TLC in Lsubclavian removed and covered with dsd, site benign, PD cath site benign covered with dsd, New PIV 20g in R forearm. Numerous open sores on extremities. Particularly bad on legs. Pt picks at them constantly and inflames them. Bleeding sores covered with dsd's. Skin otherwise intact.\n\nID: TLC tip and urine cultured. Tmax 101.1. Changing all abx to po today.\n\nPlan: CHange all meds to po and possibly call out. Continue with q3hr PD dialysate changes, set limits and redirect as needed.\n" }, { "category": "Nursing/other", "chartdate": "2204-07-27 00:00:00.000", "description": "Report", "row_id": 1515703, "text": "Nursing Progress Note.\n\nEVENTS: Fairly uneventful shift c pt now waiting for transfer to gen med floor for reduced care requirements. Pt remains a Code Grey if she attempts to leave AMA.\n\nGU: Freq of PD now changed from Q4 hrs to Q3 hrs c BUN/Cr values cont to trend downward. Dialysate remains 2.5% D5W. Urine output via foley cath noted to appear mucopurulent (UTI?), team notified and will send spot UA shortly (urine C&S sent earlier today). Pt cont to refuse quinton cath for HD therapy. Per team, the pt will not leave hosp c current PD cath in place. PD cath exit site is C/D/I.\n\nMS: Pt lethargic for most of shift, MAE, follows commands, weak, c flat affect noted. Pt c/o abd & LE pain rated and responding to 2mg IV Morphine Sulfate nicely. Pt also c/o nausea/anorexia, med c 12.5mg Anzemet @ 10:00 & 12.5mg IV Diphenhydramine @ 12:30 c mixed results (nausea should respond to ongoing PD therapy).\n\nCV: Tmax of 100.6 this AM, 100.4 most recently. Hemodynamically stable, NSR c no VEA. IV Linezolid now being changed to PO. One 20# gauge PIV in RUE. +1 LE edema c palpable pulses appreciated. AM Magnesium serum lab value of 1.6 repleted c 400mg MagOxide. Insulin sliding scale in place.\n\nRESP: Pt on RA this AM c sats generally >92% c a nl RR and no evidence of SOB/dyspnea. Pt removed 2LNCO2 when placed when sats dipped to 89% on RA when asleep.\n\nGI: As noted above, pt c poor PO intake c c/o nausea c poor responce to IV Anzemet. The pt has passed two med/small stools thus far today, guaic negative.\n\nDERM: Pt visited by skin care RN, please see skin care RN note in chart & CareVue for full impaired skin data and assoc treatments. Pt started on IV Benadryl for itching. Topical lotion applied to dry skin per skin care RN. Medium Waffle boots ordered for LE heel pressure ulcers.\n\nSOC: No calls or visitors received thus far today (though pt is making personal calls in room). The pt is a Full Code and a Code Grey should she attempt to leave AMA. Next pt conference scheduled for Monday @ noontime in MICU-A to address guardianship of children and pt placement in a supervised medical setting ( Behavioral Unit) to ensure the pts safety & well being.\n\nOTHER: Please see CareVue for additional pt care data/comments. + Contact Isolation precautions in place.\n" }, { "category": "ECG", "chartdate": "2204-08-05 00:00:00.000", "description": "Report", "row_id": 313072, "text": "Sinus rhythm. Late transition. Compared to the previous tracing of no\nsignificant change.\n\n" }, { "category": "ECG", "chartdate": "2204-07-24 00:00:00.000", "description": "Report", "row_id": 313073, "text": "Sinus rhythm. Compared to the previous tracings peaked T waves are no longer\npresent, although Q-T interval prolongation persists.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2204-07-24 00:00:00.000", "description": "Report", "row_id": 313074, "text": "Sinus rhythm. Compared to the previous tracing of Q-T interval\nprolongation persists.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2204-07-24 00:00:00.000", "description": "Report", "row_id": 313075, "text": "Sinus rhythm. Compared to the previous tracing of multiple\nabnormalities as previously noted persist without major change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2204-07-23 00:00:00.000", "description": "Report", "row_id": 313076, "text": "Sinus rhythm. Biatrial abnormality. Prolonged Q-T interval with peaked T waves\nin anterior precordial leads. Consider drug effect or metabolic abnormality.\nCompared to the previous tracing of Q-T interval prolongation and\npeaking of T waves are now more prominent.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2157-01-07 00:00:00.000", "description": "Report", "row_id": 1275790, "text": "Nursing Progress Note\nSee Carevue for details\n\nNeuro: Unresponsive, not opening eyes or following commands. Withdraws all extremities to noxious stimuli. +tremors. PERRL 2 mm bil. Appears comfortable. Mildly sedated with Propofol gtt at 5 mcg.\n\nCV: Sinus rhthym with occasional junctional beats, PAC's and PVC's. Rate ''s. BP 130's/60's. Nicardipine gtt off. +PP +CSM. No edema.\n\nResp: Vent changes per flowsheet. Currently on CPAP, 5 PEEP, 10 PS. Sats 98-100%.\n\nGI: OGT to CLWS draining bilious output. +BS. Abdomen soft. No stool this shift.\n\nGU: Foley draining CYU.\n\nEndo: FBS elevated treated with RISS.\n\nSkin: Large area of Stage I breakdown buttocks and coccyx. Very Small open area on coccyx appears to be healing ulcer. Barrier cream applied.\n\nLabs: 2nd set cardiac enzymes pending.\n\nPlan: Continue monitor neuro status, respiratory status and hemodynamics. Family will discuss changing pt's status to CMO today with team. NEOB notified per protocol.\n" }, { "category": "Nursing/other", "chartdate": "2157-01-07 00:00:00.000", "description": "Report", "row_id": 1275791, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on CPAP/PS as of 0430. Tolerating well. Vt=500-600, rr=, Ve=6-9 liters. RSBI completed on PS 5=44.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2157-01-07 00:00:00.000", "description": "Report", "row_id": 1275792, "text": "Nursing Progress note\n Please see carevue for details of care. Remains unresponsive, PERL, moves extrem on bed non purposefully. Propofol off this am. No mare awake without propofol but more tremulous and increased twitching noted in extrem. Propofol restarted. Foley draining clear yellow urine, IVF at 70 cc/hr.\n Wife and daughters in to speak w/nuero med team w/decision made to make patient CMO and withdraw supportive care after lengthy discussion r/t prognosis. Extubated at 2pm w/spont resp rate 20-26 and O2 sats 96-99% on 10L face tent. O2 removed, BP cuff off and bedside monitor off per care NP. Morphine 3-4 mg Q 15 minutes for total of 10mg and Ativan 1mg IV x2 for 2mg total w/easier resp effort and less stridor noted. Will continue to use prn meds to promote resp ease and less restlessness.\n Family remains at bedside, chaplain in to visit and pray w/famly this pm. HR remains 60's, RR 16-18. Will continue to monitor.\n PLAN: Cont CMO plan of care, offer support to family as needed, ? trans to floor if condition unchanged.\n" }, { "category": "Nursing/other", "chartdate": "2157-01-07 00:00:00.000", "description": "Report", "row_id": 1275793, "text": "RESPIRATORY CARE: PT EXTUBATED TODAY TO CMO.\nAPPEARS COMFORTABLE ON A 50 % AEROSOL MASK\nW/ SPO2 99 % AND A RR 20-22 BPM. WILL C/W\nCOMFORT MEASURES.\n" }, { "category": "Radiology", "chartdate": "2157-01-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 940949, "text": " 3:24 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval: bleed\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with head bleed\n REASON FOR THIS EXAMINATION:\n eval: bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:39 PM\n Large right temporal-occipital lobe hemorrhage, with intraventricular and\n subarachnoid space extension. Complete effacement of right atrium.\n Few mm. leftward subfalcine herniation.\n\n Hemorrhage could be into pre-existent infarction, or due to underlying amyloid\n angiopathy. Hypertension and underlying mass or vascular malformation are\n secondary diagnostic considerations.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a large intraparenchymal hemorrhage in the right temporal-\n occipital lobe with surrounding low attenuation edema. There is\n intraventricular and subarachnoid extent of the hemorrhage. There are a few\n mm of left subfalcine herniation. There is effacement of the right atrium.\n There are no acute fractures.\n\n IMPRESSION: Large right temporal-occipital hemorrhage with intraventricular\n and subarachnoid extension. This likely represents hemorrhage into a\n preexisting infarct or underlying amyloid angiopathy. Less likely\n considerations are hypertensive hemorrhage, or hemorrhage into an underlying\n mass or arteriovenous malformation.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 940946, "text": " 3:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval: tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p intub\n REASON FOR THIS EXAMINATION:\n eval: tube\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST X-RAY\n\n INDICATION: Status post intubation.\n\n COMPARISONS: None.\n\n The heart is normal in size. The mediastinal and hilar contour is\n unremarkable. The pulmonary vascularity is normal. The lungs are clear.\n There are no pleural effusions. An endotracheal tube is noted approximately 6\n cm above the carina. A nasogastric tube is well within the stomach. The soft\n tissues and osseous structures are unremarkable.\n\n IMPRESSION: Appropriate placement of endotracheal tube. Otherwise, no acute\n cardiopulmonary process identified.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2132-03-31 00:00:00.000", "description": "Report", "row_id": 1590713, "text": "CONDITION UPDATES\nPT ADMITTED FROM OR S/P (R)ORIF OF HIP AND PATELLA AFTER SLIPPING FROM PROSTHESIS. S/P OLD BKA W/ILIAC ARTEY STENTS.\nNEURO:\nINITIAL CONFUSION BUT CLEARED QUICKLY AND C/O APPROPRIATELY OF PAIN AND DISCOMFORT. NOW A+O X3 MAE (R) STUMP PAINFUL.\n\nCARDIAC:\nEXTENSIVE CARDIAC ISSUES W/ EF ONLY 20%.\nBP LOW SWAN IN PLACE AND FILLING NUMBERS LOW. GIVEN 1250ML OF FLUID TO SUPPORT POST-OP LOSSES.\n\nRESP:\nON 4LNP SAO2 99-100% CHEST SOUNDS CLEAR.\nCXR CONFIRMS PLACEMENT OF SWAN AND CLEAR LUNGS\n\nGI/GU:\nI EPISODE OF NAUSEA WITHOUT VOMITTING GIVEN ONE DOSE OF DOLASETRON WITH GOOD EFFECT.\nURINES ACCEPTED.\n\nAM LABS PENDING WILL CONTINUE TO SUPPORT BP W/FLUID PROVIDED SAO2 ACCEPTABLE\nMONITOR PAIN AND TREAT AS NEEEDED\nD'C SWAN\n" }, { "category": "Nursing/other", "chartdate": "2132-03-31 00:00:00.000", "description": "Report", "row_id": 1590714, "text": "NEURO; A&OX3, MAE, FOLLOWS COMMANDS, FREQUENTLY ANXIOUS, C/O PAIN AND MEDIC WITH MORPHINE 1 MGM AND PT STILL C/O DISCOMFORT, MEDIC WITH FENTANYL 25 MCG IV AND PT C/O THAT HE \"FELT LIKE I'M HALLUCINATING\" BUT PT WAS A&O X3 AT ALL TIMES, LATER GIVEN TYLENOL AND STATED HE FELT RELIEF\n\nCARDIOVASCULAR; HR 90'S AV PACED WITH OCCAS PVC'S, SWAN LINE DC'D AND TRIPLE LUMEN INSERTED RT IJ, CXR CONFIRMED PRESENCE, OOZING SMALL AMT SERO-SANGE DGE, SMALL HEMATOMA AT SITE, PRESSURE APPLIED BY SICU INTERN, NO FURTHER OOZING AT PRESENT,\nSTARTED ON HEPARIN GTT AT 800 UNITS/HR AT 1300, RECHECK PTT\n\nRESPIR; LUNGS CLEAR, 02 SAT 97% ON N/C AT 3 L/MIN\n\nWOUND; ORTHO TECH IN THIS PM AND SPLINT APPLIED TO STUMP AREA, PT C/O \"BURNING\" SHORTLY AFTER SPLILNT APPLIED, GIVEN ICE PACK BRIEFLY WITH RELIEF\n\nPLAN TRANSFER OUT OF SICU TO FLOOR WITH TELEMMETRY WHEN AVAILABLE, SUPPORT PT'S ANXIETY AND PAIN ISSUES,\n" }, { "category": "Nursing/other", "chartdate": "2132-04-01 00:00:00.000", "description": "Report", "row_id": 1590715, "text": "CONDITION UPDATE:\nD/A: T MAX 98.2\n\nNEURO: PT A+OX3, MAE'S, PAIN TREATED WITH TYLENOL AND PRN OXYCODONE. PT CONSULT ORDERED.\n\nCV: HR 80'S-90'S AVPACED. CVP 2-10. 2 UNITS PRBC GIVEN FOR HCT OF 21.1. POST TRANSFUSION HCT 29.0. NO S+S OF ACTIVE BLEEDING. PLATELETS 49 THIS AM, ? HIT +. TEST SENT, RETURNED NEGATIVE RESULT IN EVENING PER DR. . RESTARTED HEPARIN GTT @ 1845, CONFIRMED OK WITH DR. AND DR. . COUMADIN TO BE GIVEN TONIGHT, FIRST DOSE.\n\nRESP: LS CLEAR, DIMINISHED IN BASES. O2 SAT ~ 100% ON 3 L/M NC.\n\nGI: PT TOLERATING REGULAR LOW SODIUM DIET. NO NAUSEA, + BS.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nORTHO: RIGHT LEG DRESSING CHANGED BY ORTHO, AND NEW SUPPORT FOR LEG PLACED BY ORTHO TECH.\n\nSX: FAMILY PRESENT ALL DAY.\n\nR: AFEBRILE, VSS S/P 2 UNITS PRBC FOR LOW HCT.\n\nP: TX TO MEDICAL FLOOR WHEN BED AVAILABLE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-04-03 00:00:00.000", "description": "Report", "row_id": 1590716, "text": "NURSING NOTE\nPT TRANSFERRED FROM FLOOR SECONDARY TO NEW ONSET OF BLEEDING INTO R HOP PER CT SCAN AND NEED FOR CLOSER MONITORING.\nNEURO: PT ANXIOUS AT TIMES REGARDING POSTIONING AND PAIN. FOLLOWS COMMANDS AND MAE'S APPROP. AFEBRILE\nCV: V-PACED, RATE 70'S. SBP 90-110 SYS. NS AT 75CC VIA R IJ LINE. LOW, MD AWARE AND NO TREATMENT. SERIAL HCTS, CURRENTLY 30 WITH NO TRANSFUSION THUS FAR.\nRESP:LS CLEAR,DIMINISHED. ENC TO C+DB. 2L NC ON. SOME COUGHING NOTED POST DRINKING WATER- WILL CONT TO .\nGI: ABD SOFT,NT,ND. LOOSE BROWN FOUL SMELLING STOOL, CDIFF FROM FLOOR PENDING.\nGU:FOLEY PATENT CLEAR YELLOW URINE.\nSKIN: R HIP DRSG AMOUNT BLOOD DRNG. R KNEE DRESSING INTACT.\nSOCIAL: DAUGHTER CALLING FOR UPDATES.\n\nPLAN:CONT TO MONITOR SERIAL HCT'S, , DRESSING. NPO.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-04-04 00:00:00.000", "description": "Report", "row_id": 1590717, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT ALERT AND ORIENTED X 3. C/ PAIN IN R KNEE AREA, INTERMITTENT THAT \"FEELS LIKE A WAVE\" PER PT'S DESCRIPTION. MORPHINE GIVEN WITH SMALL AMOUNT OF RELIEF, TYLENOL NOT HELPFUL, DILAUDID 1MG GIVEN X 2 WITH EXCELLENT EFFECT. PATIENT PAINFREE THIS AM.\nCV- BP STABLE 90-100 SYSTOLIC. HR 70-80'S WITH OCCASIONAL PVCS. PT HAS AICD?, NO PACER SPIKES NOTED ON EKG STRIP. RECEIVED ONE UNIT OF PRBCS FOR HCT 28, HCT INCREASED TO 34 THIS AM. NO LASIX FOLLOWING PRBCS PER DR. .\nRESP- LUNGS CLEAR, 3L NC WITH SATS 97-100%.\nGI/GU- ABD SOFT, NPO. REFUSED NEUTRA PHOS STATING, \"THAT WILL MAKE ME SICK IF I DRINK IT\". DR. NOTIFIED. UOP MINIMAL OVERNIGHT, AVERAGING 10-12CC/HR, DR. NOTIFIED, MAINTENANCE FLUID REMAINING AT 75CC/HR OVERNIGHT.\nSKIN- RIGHT HIP INCISION OOZING SCANT AMOUNTS OF BLOOD, DRESSING CHANGED AND KEPT CLEAN. BRUISING APPEARING TO STAY THE SAME OVERNIGHT. RIGHT KNEE DRESSING DRY AND INTACT.\nID- AFEBRILE\nPLAN- CONTINUE Q 4HOUR HCTS, MONITOR RIGHT HIP FOR FURTHER BLEEDING/PAIN, OFFER EMOTIONAL SUPPORT.\n" }, { "category": "Radiology", "chartdate": "2132-03-30 00:00:00.000", "description": "R KNEE (2 VIEWS) RIGHT", "row_id": 863847, "text": " 6:47 PM\n HIP UNILAT MIN 2 VIEWS RIGHT IN O.R.; KNEE (2 VIEWS) RIGHT Clip # \n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT\n Reason: HIP FX\n Admitting Diagnosis: RIGHT PATELLA FX-LEFT FEMORAL NECK FX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hip fracture.\n\n RIGHT HIP/LEG INTRAOPERATIVE RADIOGRAPHS: Five intraoperative radiographs\n were obtained. Three femoral head fixation screws are present within the\n proximal right femur. No fracture line is visible on these radiographs.\n There is anatomic alignment. Additional films demonstrate screw fixation of\n the patella. The prior seen fracture on films has been reduced.\n There is anatomic alignment.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-04-03 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 864381, "text": " 1:17 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Please evaluate for RP bleed, please re-evaluate size of ane\n Admitting Diagnosis: RIGHT PATELLA FX-LEFT FEMORAL NECK FX\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with severe PVD, known AAA 5.4x5.0 cm, cardiovascular disease,\n s/p R BKA, here with femur and patellar fracture now s/p ORIF and patellar\n repair, with continually dropping hct post-op.\n REASON FOR THIS EXAMINATION:\n Please evaluate for RP bleed, please re-evaluate size of aneurysm and\n integrity, if possible please also look for bleeding into R hip.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 78-year-old male with peripheral vascular disease, AAA, and right\n below-the-knee amputation with femur, and patellar fractures with decreased\n hematocrit.\n\n TECHNIQUE: Axial CT imaging of abdomen and pelvis performed before and after\n the intravenous administration of 150 cc of Optiray. Nonionic contrast was\n used due to patient debility.\n\n CT OF THE ABDOMEN WITH CONTRAST: There is extensive emphysema within the\n visualized portions of lung bases with small bilateral pleural effusions. The\n liver has a nodular contour suggestive of possible underlying emphysema. There\n is a moderate amount of intra-abdominal ascites. Spleen, kidneys, small\n bowel, and colon are unremarkable. No pathologically enlarged retroperitoneal\n or mesenteric lymph nodes are seen. Edema is present within the subcutaneous\n tissues of the abdomen.\n\n An infrarenal abdominal or aortic aneurysm is present measuring 5.5 x 5.2 cm.\n This aneurysm measured 4.6 x 4.2 cm on . Noncontrast imaging of\n this abdominal aortic aneurysm showed evidence of hyperdensity within the\n periphery of this abdominal aortic aneurysm suggestive of subacute thrombus.\n\n CT OF THE PELVIS WITH CONTRAST: The urinary bladder is normal with a Foley\n catheter in place. There is a small amount of free fluid within the pelvis\n with hedging appearances consistent with simple fluid. The rectum is\n unremarkable.\n\n There is a large right thigh hematoma with active extravasation of contrast\n present from a muscular branch of the profunda femoris artery during the\n arterial phase of contrast administration.\n\n There is a orthopedic screws within the right proximal femur.\n\n IMPRESSION:\n 1. Active arterial extravasation within the right thigh from a muscular branch\n of the right profunda femoris artery. Associated large right thigh\n intramuscular hematoma.\n (Over)\n\n 1:17 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Please evaluate for RP bleed, please re-evaluate size of ane\n Admitting Diagnosis: RIGHT PATELLA FX-LEFT FEMORAL NECK FX\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n 2. Interval enlargement of an infrarenal abdominal aortic aneurysm measuring\n 5.6 cm in greatest dimension that has increased in size when compared to\n , demonstrates hyperdense thrombus within the periphery of this\n aneurysm. This so-called crescent sign can be seen with impending rupture and\n close clinical correlation of this patient and vascular surgery consultation\n is suggested.\n\n 3. Moderate amount of intra-abdominal ascites with a nodular appearance of a\n liver suggestive of possible underlying liver disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 863924, "text": " 10:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pneumo, line position\n Admitting Diagnosis: RIGHT PATELLA FX-LEFT FEMORAL NECK FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78M s/p s/p cvl change\n REASON FOR THIS EXAMINATION:\n please eval for pneumo, line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old post-central line change, assess for pneumothorax.\n\n PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH. Comparison is made to one day\n earlier.\n\n FINDINGS:\n\n The previously seen Swan-Ganz catheter has been removed and there is a right\n internal jugular central venous catheter. The tip of the catheter is not\n clearly visualized as it is obscured by the ICD lead from the pacemaker. It\n appears, however, to be within the mid to distal portion of the SVC. There is\n a small right apical pneumothorax, which is largely unchanged from the prior\n study. Cardiac and mediastinal contours are unchanged. The lungs remain\n essentially clear.\n\n IMPRESSION:\n\n Unchanged appearance of small right apical pneumothorax. Right IJ central\n venous catheter whose tip is not clearly seen, but is likely within the mid to\n distal SVC.\n\n" }, { "category": "Radiology", "chartdate": "2132-03-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 863864, "text": " 11:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tip position\n Admitting Diagnosis: RIGHT PATELLA FX-LEFT FEMORAL NECK FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78M s/p swan placement in OR\n REASON FOR THIS EXAMINATION:\n eval for tip position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swan-Ganz catheter placement in operating room.\n\n Comparison is made to .\n\n A Swan-Ganz catheter is present, terminating within the intralobar portion of\n the right pulmonary artery. There is a small right apical pneumothorax\n present. An ICD with biventricular pacing leads is noted. The heart size is\n normal, and the lungs demonstrate emphysema, grossly clear.\n\n IMPRESSION: Swan-Ganz catheter terminates in interlobar portion of right\n pulmonary artery. Small right apical pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-04-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 864181, "text": " 8:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for intervalm increase in PTX\n Admitting Diagnosis: RIGHT PATELLA FX-LEFT FEMORAL NECK FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with right hip fracture, small PTX\n\n REASON FOR THIS EXAMINATION:\n please assess for intervalm increase in PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man with right hip fracture, small pneumothorax.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: Chest x-ray dated .\n\n FINDINGS: The patient is status post aortic valve replacement with median\n sternotomy. Right IJ line and cardiac pacemaker leads remain in place. Note\n is made of resolving right apical pneumothorax. Note is made of emphysematous\n change of the lung. Bilateral lower lobe atelectasis is again noted.\n\n IMPRESSION: Resolving right apical small pneumothorax. Emphysema.\n Atelectasis at the lung bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-03-28 00:00:00.000", "description": "R PATELLA (AP, LAT & SUNRISE) RIGHT", "row_id": 863662, "text": " 8:31 PM\n PATELLA (AP, LAT & SUNRISE) RIGHT Clip # \n Reason: assess for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with marked knee pain and tenderness at R kneecap after direct\n fall onto it.\n REASON FOR THIS EXAMINATION:\n assess for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Knee pain and tenderness over patella after fall.\n\n AP, LATERAL AND SUNRISE VIEWS OF THE PATELLA: No prior studies are available\n for comparison. There is a horizontal fracture through the patella with 1.2\n cm of displacement of the fragments anteriorly. There is a small joint\n effusion. There are changes from prior BKA, and extensive vascular\n calcifications are present.\n\n IMPRESSION: Horizontal patellar fracture with 1.2 cm of displacement\n anteriorly.\n\n" }, { "category": "ECG", "chartdate": "2132-04-02 00:00:00.000", "description": "Report", "row_id": 105585, "text": "Dual chamber electronic pacemaker in atrial sensing - ventricular pacing mode.\nQRS configuration suggest fusion beats. Compared to the previous tracing\nof ventricular ectopy less prominent.\n\n" }, { "category": "ECG", "chartdate": "2132-03-31 00:00:00.000", "description": "Report", "row_id": 105586, "text": "Ventricular paced with ectopic beats\nSince last ECG, ventricular paced with ectopic beats\n\n" }, { "category": "ECG", "chartdate": "2132-03-29 00:00:00.000", "description": "Report", "row_id": 105587, "text": "Dual chamber electronic pacemaker in atrio-ventricular sequential pacing mode.\nCompared to the previous tracing no major change.\n\n" }, { "category": "Radiology", "chartdate": "2132-03-28 00:00:00.000", "description": "R HIP UNILAT MIN 2 VIEWS RIGHT", "row_id": 863639, "text": " 3:56 PM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: right hip fracture?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with fall, ?fracture on films from , not c/w exam, pain\n in knee, hip benign.\n REASON FOR THIS EXAMINATION:\n right hip fracture?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old man status post fall.\n\n PELVIS AND RIGHT HIP, THREE VIEWS: There is a transverse lucency through the\n femoral neck, which may represent a nondisplaced fracture. No other fractures\n or dislocations are identified. Degenerative changes of the SI and hip joints\n are noted. There is diffuse demineralization. Extensive vascular\n calcifications and iliac stents are noted.\n\n IMPRESSION: Transverse lucency through the femoral neck, which may represent\n a nondisplaced fracture.\n Recommend CT as patient cannot have MR exam.\n\n" }, { "category": "Radiology", "chartdate": "2132-03-28 00:00:00.000", "description": "CT RECONSTRUCTION", "row_id": 863647, "text": " 4:53 PM\n CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # \n Reason: right femoral neck fracture?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with right femoral neck fracture on x-ray after fall.\n REASON FOR THIS EXAMINATION:\n right femoral neck fracture?\n CONTRAINDICATIONS for IV CONTRAST:\n cri\n ______________________________________________________________________________\n WET READ: JCT FRI 6:19 PM\n nondisplaced fracture of the right femoral neck\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old man with right femoral neck fracture on plain films.\n\n TECHNIQUE: Multidetector axial images were obtained from the iliac crests to\n the mid femurs without contrast. Axial and coronal reformatted images were\n obtained.\n\n There is a nondisplaced fracture of the proximal right femoral neck. No other\n fractures or dislocations are identified. There is diffuse osteopenia. There\n is a small amount of high attenuation fluid within the right hip joint space,\n which may represent a small amount of hemorrhage. Extensive vascular\n calcifications are seen as are bilateral iliac stents. Visualized portions of\n the pelvis are unremarkable. Soft tissue structures are within normal limits.\n\n IMPRESSION: Nondisplaced fracture of the right femoral neck.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2133-02-09 00:00:00.000", "description": "CT RECONSTRUCTION", "row_id": 852569, "text": " 8:28 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: TRAUMA REQUIRING INTUBATING\n ______________________________________________________________________________\n WET READ: VK MON 9:40 PM\n No fx. Blebs in lung apices suggestive of COPD.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 47-year-old in rollover motor vehicle accident.\n\n TECHNIQUE: CT of the cervical spine without IV contrast. Coronal and\n sagittal reformatted images were obtained.\n\n FINDINGS:\n\n On the sagittal projection, the C1 through upper portion of the T2 vertebral\n bodies are seen. There is normal vertebral body height and alignment. The\n disc spaces are normal. No fractures are identified. The caliber of the\n spinal canal is unremarkable. An endotracheal tube and NG tube are present.\n Prevertebral soft tissues are unremarkable.\n\n The visualized portion of the upper lung fields demonstrates several small\n apical blebs.\n\n IMPRESSION:\n 1. No fracture seen in the cervical spine. Small blebs in the lung apices\n suggestive of COPD.\n\n" }, { "category": "Radiology", "chartdate": "2133-02-09 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 852570, "text": " 8:29 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: sp polytrauma\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with\n REASON FOR THIS EXAMINATION:\n sp polytrauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: VK MON 10:08 PM\n No evid of traumatic injury. Bibasilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION; 47 year old in roll over MVA.\n\n TECHNIQUE: CT of the chest, abdomen and pelvis with IV contrast. 150 cc of\n Optiray were used for this examination due to patient history of debility.\n Coronal and sagittal reformatted images were obtained.\n\n No prior studies for comparison.\n\n CT CHEST WITH IV CONTRAST:\n There are no pleural effusions. There are a few tiny nonpathologically\n enlarged prevascular lymph nodes. There is no significant axillary or hilar\n lymphadenopathy. Lung windows demonstrate several small blebs at the lung\n apices. There is no pneumothorax. There is bibasilar atelectasis. The\n bronchi are patent to the subsegmental level. An endotracheal tube is present\n with its tip terminating at the thoracic inlet. An NG tube is seen within the\n esophagus. A small amount of soft tissue density is seen in the distal\n trachea just above the carina likely representing secretions. The heart and\n pericardium are unremarkable. The aorta and pulmonary artery are normal in\n appearance with no evidence of traumatic injury. Note is made of 5 mm nodule\n within the right lobe of the thyroid.\n\n CT ABDOMEN WITH IV CONTRAST:\n Several small hypodensities are seen scattered throughout the liver.\n Attenuation values range from 14-40 which is not typical of simple cysts.\n These may represent small hemangiomas though they are not fully characterized\n on this study. The liver is otherwise unremarkable in appearance. The\n spleen, pancreas, gallbladder, intraabdominal large and small bowel, and\n intraabdominal vasculature are unremarkable. The left kidney is normal in\n appearance. The right kidney contains several small hypodensities consistent\n with small cysts. The right kidney is otherwise normal. Both kidneys enhance\n symmetrically. No free air, free fluid, or pathologic lymphadenopathy is seen\n within the abdomen. A few clips are seen around the greater curvature of the\n stomach.\n\n CT PELVIS WITH IV CONTRAST:\n The rectum, sigmoid, and bladder are unremarkable. A Foley catheter is seen\n within the bladder with a resultant small amount of air. The prostate is\n (Over)\n\n 8:29 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: sp polytrauma\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n unremarkable. No free fluid or lymphadenopathy is seen in the pelvis.\n\n The soft tissues and osseous structures are unremarkable with no evidence of\n fracture.\n\n Coronal and sagittal reformatted images confirm the above findings.\n\n IMPRESSION:\n 1) No evidence of traumatic injury within the chest, abdomen, or pelvis.\n\n 2) ET tube at the level of the thoracic inlet which should be advanced.\n\n 3) Small blebs at both lung apices suggestive of underlying COPD. Bibasilar\n atelectasis.\n\n 4) Hypodensities seen scattered throughout the liver. If further\n characterization is required, an elective ultrasound could be performed.\n\n 5) Small nodule in the right lobe of the thyroid.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-02-10 00:00:00.000", "description": "Report", "row_id": 1298923, "text": "t/sicu admission note 2a-730a\n pt is an unrestrained driver who rearended parked car. windsheild starred. arrived at ew combative and belligerant so intubated in order to get ct scans. pan scan negative. no injuries known. etoh 350. to sicu for ventilator management.\n\npmhx: unknown\nall: unknown\nmeds: unknown\n\nreview of systems\n\nneuro: arrived on propofol gtt. when lightened pt very agitated but following commands consistantly with all extremeties. pearl. resedated on propofol d/t pt attempting to pull out ett. ativan 1mg iv x1 given for agitation.\n\ncv: hemodynamically stable.\n\nresp: l/s clear and diminished at bases. fully vented d/t sedation.\nabg adequate.\n\ngi: abd softly with +bs. nontender on palpation. ogt to sx draining mod amt of thick brown material. no stool or flatus.\n\ngu: u/o adequate. ivf d5lr at 100cc/hr. lytes wnl\n\nheme: stable\n\nendo: no issues\n\nid: no issues.\n\nskin: no issues.\n\nsocial: no family contact. pt head no when asked if he wanted us to contact anyone.\n\nplan: wean and extubate this am and ? discharge to home later today\n\n" }, { "category": "Nursing/other", "chartdate": "2133-02-10 00:00:00.000", "description": "Report", "row_id": 1298924, "text": "Resp Care Note.\n\nPt was admitted via ED after MVA involving ETOH. Settings are simv 12, vt 550, , 50%. Pt is combative when not sedated. All ct scans were negative. RSBI 20, ABG showing mild resp acidosis and hyperoxemia\n" } ]

[ { "category": "Radiology", "chartdate": "2199-07-15 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1146146, "text": " 3:35 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please eval line\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p RIJ placement\n REASON FOR THIS EXAMINATION:\n please eval line\n ______________________________________________________________________________\n WET READ: LLTc MON 4:04 PM\n New Right IJ terminating at the cavalatrial junction. There is no\n pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right IJ placement.\n\n COMPARISON: Radiograph available from at 13:12.\n\n TECHNIQUE: Frontal upright chest radiograph.\n\n FINDINGS: The patient is status post placement of the right-sided IJ\n catheter, which terminates at the cavoatrial junction. No pneumothorax is\n present. The cardiomediastinal silhouette is grossly unchanged since the\n prior radiograph from 1:12 p.m. There is mild bibasilar atelectasis in the\n setting of relatively low lung volumes.\n\n IMPRESSION: Status post placement of the right IJ, which terminates at the\n cavoatrial junction. There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2199-07-16 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 1146222, "text": " 3:50 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: DISTENDED ABD\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with acute renal failure, distended tense abdomen\n REASON FOR THIS EXAMINATION:\n assess for intra-abdominal pathology\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: SPfc TUE 5:11 AM\n Very large volume of retained stool in the colon, predominantly in the cecum\n and transvers colon. No other apparent etiology to abdominal pain\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute renal failure and tense abdomen.\n\n COMPARISON: Renal ultrasound from and CT from .\n\n TECHNIQUE: Axial CT images were acquired through the abdomen and pelvis\n without the use of intravenous contrast. Coronal and sagittal reformatted\n images were also reviewed.\n\n CT ABDOMEN WITHOUT CONTRAST: The imaged portions of the lung bases are\n notable for mild subsegmental dependent atelectasis. A nasogastric tube ends\n in the stomach. The spleen, duodenum, fatty pancreas, adrenal glands,\n kidneys, gallbladder, and liver are unremarkable. There is no free gas or\n fluid in the abdomen. There is no retroperitoneal or mesenteric\n lymphadenopathy. Regional vascular structures are unremarkable. Note is made\n of a tiny fat-containing umbilical hernia.\n\n CT PELVIS WITHOUT CONTRAST: The urinary bladder contains a Foley catheter.\n The prostate and seminal vesicles are unremarkable. The colon is notable for\n an extremely large volume of retained stool predominantly in the cecum and\n transverse colon with relatively little seen in the distal . There is no\n free gas or fluid in the pelvis. There is no pelvic sidewall or inguinal\n lymphadenopathy.\n\n OSSEOUS FINDINGS: Note is made of degenerative change including extensive\n subchondral cystic formation at the hip joints which has progressed since\n . Degenerative change is also noted in the spine. There is no suspicious\n sclerotic or lytic osseous lesion.\n\n IMPRESSION:\n 1. Large volume of retained stool in the colon.\n 2. Progressive degenerative change involving the hips.\n (Over)\n\n 3:50 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: DISTENDED ABD\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Echo", "chartdate": "2199-07-16 00:00:00.000", "description": "Report", "row_id": 97515, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure.\nHeight: (in) 73\nWeight (lb): 190\nBSA (m2): 2.11 m2\nBP (mm Hg): 160/68\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 14:45\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\nLV wall motion abnormality cannot be fully excluded. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Aortic valve not well seen. No AS. No AR.\n\nMITRAL VALVE: Mitral valve leaflets not well seen.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity size is normal.\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve is not well seen. There is probably no aortic valve stenosis\nbut transvalvular velocities were suboptimally assessed. No aortic\nregurgitation is seen. The mitral valve is probably structurally normal (views\nsuboptimal) with trivial mitral regurgitation. There is no pericardial\neffusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, there is no definite change.\n\n\n" }, { "category": "ECG", "chartdate": "2199-07-17 00:00:00.000", "description": "Report", "row_id": 268542, "text": "Sinus tachycardia. Diffuse non-specific ST-T wave change. Compared to the\nprevious tracing of the rate has increased. Variation in precordial\nlead placement. No diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2199-07-16 00:00:00.000", "description": "Report", "row_id": 268543, "text": "Baseline artifact. Sinus rhythm. Since the previous tracing there is probably\nno significant change. There appear to be small R waves in leads V1-V2.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2199-07-15 00:00:00.000", "description": "Report", "row_id": 268544, "text": "Sinus rhythm. P-R interval prolongation. Low voltage. Since the previous\ntracing the QRS has narrowed. T waves are improved. Clinical correlation is\nsuggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2199-07-15 00:00:00.000", "description": "Report", "row_id": 268545, "text": "Sinus rhythm at upper limits of normal rate. Since the previous tracing the\nT waves are less peaked. Otherwise, findings are unchanged.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2199-07-15 00:00:00.000", "description": "Report", "row_id": 268546, "text": "Probable sinus tachycardia. Marked P-R interval prolongation. Consider left\natrial abnormality. Leftward axis. Somewhat late R wave progression. Peaked\nprecordial T waves with short Q-T interval - consider hyperkalemia. Since the\nprevious tracing of the rate is faster. P-R interval is longer, voltage\nis diminished, the QRS complex is wider and T waves are peaked. Clinical\ncorrelation is suggested.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2165-05-13 00:00:00.000", "description": "Report", "row_id": 1381094, "text": "TSICU Nursing Admit Note\nPt is 51y.o. female admitted to TSICU from OR S/P R breast reconstruction with abdominal free flap. Accompanied by anesthesia with stable vitals on admit(see care view for specifics) and O2 sats of 100% on face mask at 5L. Drowsy, but alert and oriented. C/O abdominal pain--MSO4 IVP given per anesthesia. Pt's PMH consists of R breast mastectomy for CA in (radiation at this time also.) In she also had L partial mastectomy for CA. Right total hip replacement in .\n\nREVIEW of SYSTEMS:\nNeuro...Drowsy, but when stimulated, A&Ox3, follows commands, cooperative. Moves all extremities well. C/O abd pain. MSO4 PCA started. 2mg bolus given initially. Reports better pain relief now.\n\nCV...NSR with no ectopy noted. HR 90's. BP 120's/60-70's. Palpable peripheral pulses. LR at 100cc/hr.\n****Flap checks to flap site R breast Q15min. Strong arterial signal. Pale color, but slight cap refill--no change since admission to unit.\n\nRESP..Weaned to NC at 2L/min. O2 sats >96%. Lung sounds clear but mildly diminshed to bases. Needs IS.\n\nGI...NPO. Given ice chips tolerated well. Abd flat, softly distended. Absent BS.\n\nGU...Foley with adequate clear yellow urine output. Chemistry sent. Results pending.\n\nHEME...HCT post op 32. Pneumo boots on. Aspirin to be given.\n\nID...99.3 tax. No abx.\n\nSKIN... R breast incisions well approximated with transparent dsg covering. JP x1 with small amts of sang drg. Lower abd transverse incision well approximated with transparent dsg also. JP's x2 with small amt sang drg.\n\nSOCIAl... husband in to visit. Updated per attending PLS MD, Dr. , on pt's condition.\n" }, { "category": "Nursing/other", "chartdate": "2165-05-13 00:00:00.000", "description": "Report", "row_id": 1381095, "text": "Nursing Note: ADDENDUM 4pm-7pm\nSee admission note:\n\nHemodynamic status stable, utlizing mso4 PCA as indicated, Dopper pulse check continue q 15 min., pulse present, + cap. refill. Abd, flat, tender, jp drains intact. ASA given as per order. Sleeping in naps. Husband at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2165-05-14 00:00:00.000", "description": "Report", "row_id": 1381096, "text": "T/SICU RN Progress Note\nNeuro: Sleeping on/off most of shift, oriented. PCA for pain with good results, needed 2mg morphine for breakthrough pain X1 with good effect.\n\nCV: HR 80-90's SR no ectopy NBP 100's systolic. IVF @100cc/hr. P-boots on. Flap checks as ordered Q15min, Q30mins, Q1hr started at 2am. Pulses good, +CAP refill, flap warm to touch.\n\nResp: Lungs clear decreased in bases Sats 94-97% on 2ln/c.\n\nGU/GI: Foley with clear yellow urine. NPO except ice chips.\n\nSkin/Mobility: Right breast and abdomen dressings intact, with JP's x3 with s/s drainage. Bed remains in jacknife position at all times.\n\nSocial: Husband home for the night, called and updated.\n\nA: s/p tram flap\n\nPlan: Cont to monitor flap for pulses and cap refill/temp. pain control as needed, transfer to floor when ready.\n" }, { "category": "Nursing/other", "chartdate": "2165-05-14 00:00:00.000", "description": "Report", "row_id": 1381097, "text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: SLEEPY. AROUSABLE. MORPHINE PCA WEANED TO PO\n PERCOCET WITH GOOD EFFECT. TYLENOL GIVEN FOR\n HEADACHE. C/O \"DIZZINESS.. BLURRED VISION.\"\n ...WHICH SEEMS TO BE IMPROVING.\n\nCV: HR AND BP STABLE.\n\nRESP: 2LNC OR ROOM AIR WITH ENCOURAGEMENT TO\n C AND DB/INCENTIVE SPIROMETRY WHEN SAT\n DROPS.\n\nRENAL: NO LABS SENT. LOW UO.\n\nGI: HOUSE DIET. TAKING FLUIDS. IVF AT KVO.\n\nHEME: NO LABS. SC HEPARIN BEGUN. BOOTS ON.\n 3 JP'S...WITH SEROSANG DRAINAGE.\n\nENDO: NO LABS.\n\nID: AFEBRILE. IV KEFZOL.\n\nSKIN: FLAP PULSE DOPPLERABLE. OR INCISIONS INTACT.\n GOOD COLOR AND SENSATION.\n\nSOCIAL: DAD AND HUSBAND CALLED.\n\nACTIVITY: BED REMAINS JACKNIFED. MOVING BETTER IN BED.\n\n\nA: STABLE S/P BREAST RECONSTRUCTION.\nP: PULSE CHECKS CONTINUE Q1 HOUR.\n" }, { "category": "Nursing/other", "chartdate": "2165-05-14 00:00:00.000", "description": "Report", "row_id": 1381098, "text": "TSICU NPN\nFlap checks remain intact with strong doppler signal and nice cap refill. Increasing mobility noted this afternoon--moving self around in bed more. Percocet for c/o incisional pain providing adequate relief. Bout of nausea x1 with zofran given--good effect. House diet ordered. Taking in little food. Urine output down all afternoon. Notified Dr. at 1830. Will encourage PO intake. IVF's HL'd at this time.\n" }, { "category": "Nursing/other", "chartdate": "2165-05-15 00:00:00.000", "description": "Report", "row_id": 1381099, "text": "T/SICU RN Progress Note\nNeuro: Alert and oriented, pleasant percocet for pain with effect, due to n/v changed to morphine with good effect.\n\nCV: HR 80's SR no ectopy noted, NBP systolic 120's, P-boots, SQ Heparin, IVF restarted at 80cc/hr due to n/v. Flap with strong doppler pulse, good cap refill, and warm to touch.\n\nResp: Lungs clear, C/DB encouraged sats down to 88 when sleeping, up to 95 when in 2ln/c.\n\nGU/GI: Foley with clear yellow urine. N/V overnight vomited X3 tol. sips of water only. Zofran with effect, IVF started.\n\nSkin/Mobility: Bed in jacknife position, dressings intact, JP's to self suction.\n\nSocial: Husband and father called updated by this RN and spoke to patient.\n\nA: S/P tram flap\n\nPlan: Doppler checks Q1hr on flap until 2am on , advance diet as tolerated, cont to monitor and support, follow plan of care.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2186-07-16 00:00:00.000", "description": "REDUCED SERVICES", "row_id": 971639, "text": " 12:57 AM\n SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING; -52 REDUCED SERVICESClip # \n Reason: r/o metal fb\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with paralysis - needs MRI\n REASON FOR THIS EXAMINATION:\n r/o metal fb\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Paralysis, needs MRI, rule out metal foreign body.\n\n Frontal view of the skull and frontal view of the lumbar spine were compared\n to subsequently obtained cross-sectional imaging from same day. The patient\n is status post right frontal craniectomy with multiple craniectomy clips.\n In addition, there is a dense metallic object overlying the right frontal lobe\n of unknown etiology, but likely postoperative. No metallic densities are\n noted overlying the orbits or pelvis. Bowel gas pattern is normal.\n\n IMPRESSION: Large metallic object overlying the right frontal lobe of\n uncertain etiology but likely related to prior cranial surgery. Comparison\n with operative notes would likely determine etiology and confirm MR\n compatible.\n\n" }, { "category": "Radiology", "chartdate": "2186-07-16 00:00:00.000", "description": "CT L-SPINE W/O CONTRAST", "row_id": 971641, "text": " 1:27 AM\n CT T-SPINE W/O CONTRAST; CT L-SPINE W/O CONTRAST Clip # \n Reason: ?mets, compression fx? cord compression?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with esophogeal CA and LE weakness and back pain. Metallic\n object in head --> no mri possible.\n REASON FOR THIS EXAMINATION:\n ?mets, compression fx? cord compression?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD SUN 3:00 AM\n No acute fx or malaligment. No malignant appearing lesions. Epidural\n lipomatosis extending from t5 to sacrum present, but unlikely to explain pts\n myelopathy as cord does not appear compressed. Metastatic lesions to meninges\n or cord not evaluated by CT but remains in differential.\n\n Esophageal stent with wall thickening consistent with known esophageal\n\n Neuroradiology overread:\n The amount of epidural fat is not abnormal.\n The CSF around the cord is hazy. Uncertain if this is artifact or actual\n lesion: In a PT with carcinoma and severe leg weakness, meningeal or cord\n metastases need to be excluded. Options include CT myelography or MRI after\n obtaining safety info about the intracranial surgical metal.\n There is no mechanical external impingement on the cord such as epidural\n lesion or bone destruction\n\n MD\n WET READ VERSION #1 JKPe SUN 2:26 AM\n No acute fx or malaligment. No malignant appearing lesions. Epidural\n lipomatosis extending from t5 to sacrum may explian pts myelopathy.\n Esophageal stent with wall thickening consistent with known esophageal\n WET READ VERSION #2 JKPe SUN 2:53 AM\n No acute fx or malaligment. No malignant appearing lesions. Epidural\n lipomatosis extending from t5 to sacrum present, but unlikely to explain pts\n myelopathy as cord does not appear compressed. Metastatic lesions to meninges\n or cord not evaluated by CT but remains in differential.\n\n Esophageal stent with wall thickening consistent with known esophageal\n\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old man with esophageal cancer and new lower extremity\n paralysis starting today with progressive back pain over last few days. Unable\n to obtain MRI due to prior craniotomy and clip within the brain parenchyma.\n Evaluate for etiology.\n\n Comparison is made to T-spine radiographs from same day.\n\n CT OF THE THORACIC/LUMBAR SPINE\n\n TECHNIQUE: MDCT acquired axial images are obtained of the thoracic and lumbar\n (Over)\n\n 1:27 AM\n CT T-SPINE W/O CONTRAST; CT L-SPINE W/O CONTRAST Clip # \n Reason: ?mets, compression fx? cord compression?\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n spine without intravenous contrast. Coronal and sagittal reformations were\n evaluated.\n\n FINDINGS: There appears to be visible epidural fat, extending from the level\n of T5 superiorly down to the sacrum. Vertebral body heights and alignment\n appear preserved. No malignant-appearing osseous lesions are identified. The\n visualized contents of the thecal sac appear otherwise unremarkable, aside\n from a few punctate gas bubbles in the upper thoraic epidural space- has\n there been recent intravenous line insertion, with possible migration of gas\n via that route into a few epidural veins?\n\n There is identification of a large metallic esophageal stent and esophageal\n wall thickening noted superior to the stent and inferior to the stent,\n consistent with patient's known history of esophageal cancer. Visualized\n portions of the lungs appear unremarkable; the airways appear patent, with a\n small amount of secretions noted within the right main stem bronchus.\n Atherosclerotic disease is noted within the abdominal aorta.\n\n IMPRESSION:\n 1. No overt cord compression due to osseous or epidural disease, within the\n limitations of this non-contrast CT scan. Meningeal or cord metastases cannot\n be excluded, nor can a paraneoplastic syndrome.\n 2. Esophageal wall thickening with esophageal stent in place, with soft\n tissue density noted within the lumen, consistent with patient's history of\n esophageal cancer. Density within the lumen may represent retained food\n products; however, extension of tumor through the stent cannot be excluded.\n 3. Mild amount of secretions noted within the right mainstem bronchus.\n\n Findings discussed with Dr. on date of exam at approximately 2:30\n a.m.\n\n This study was also reviewed by Dr. , Nighthawk neuroradiologist,\n and the above-noted findings are in agreement with his preliminary assessment.\n Given the patient's present inability to obtain an MRI, further intrathecal\n detail could be obtained with a CT myelogram.\n\n As was discussed with Dr. , interventional neuroradiologist this\n morning (8AM), pre-procedural non-contrast head CT scan and cervical spine\n CT scans would help to exclude unanticpated neoplastic lesions in these\n locales.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-07-20 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 972401, "text": " 9:20 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for opacification of lungs\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with esophageal CA and spinal shock, hypoxia, dyspnea\n REASON FOR THIS EXAMINATION:\n eval for opacification of lungs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Esophageal cancer and spinal shock, hypoxia, and dyspnea.\n\n COMPARISON: , , and .\n\n AP PORTABLE UPRIGHT VIEW OF THE CHEST: Opacification of the right hemithorax\n with ipsilateral mediastinal shift is again noted. The aerated portion of the\n lung is slightly increased in opacity compared to the previous study. Left\n lung is grossly clear. Esophageal stent is noted. No evidence of\n pneumothorax.\n\n IMPRESSION: Interval slight worsening in opacity of the remaining aerated\n lung on the right.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-07-19 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 972187, "text": " 6:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for mucous plugging/lung collapse\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with esophageal CA and spinal shock, new acute hypoxia\n\n REASON FOR THIS EXAMINATION:\n assess for mucous plugging/lung collapse\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Acute hypoxia, assess for lung collapse. Patient with\n esophageal carcinoma and spinal shock.\n\n Note is made that the right lateral hemithorax was not included on the film,\n allowing this limitation, there is complete opacification of the visualized\n portion of the right hemithorax. This is consistent with right lung collapse.\n The cardiomediastinum is shifted towards the right side. Compared to prior\n study CT chest dated , there is improved aeration in the left lung\n in the lingula and lower lobe.\n\n" }, { "category": "Radiology", "chartdate": "2186-07-16 00:00:00.000", "description": "MYELOGRAM 2 OR MORE REGIONS, S&I", "row_id": 971675, "text": " 9:06 AM\n MYELOGRAM Clip # \n Reason: Please obtain CSF for diagnostic studies and myelogram to as\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Contrast: NON IONIC Amt: 7\n ********************************* CPT Codes ********************************\n * INJ PROC. FOR MYLEO MYELOGRAM 2 OR MORE REGIONS, S *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with esophageal cancer and paraplegia\n REASON FOR THIS EXAMINATION:\n Please obtain CSF for diagnostic studies and myelogram to assess blockage.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF STUDY: Fluoroscopic guided lumbar axis myelogram.\n\n CLINICAL HISTORY: 51-year-old male with esophageal cancer, now presents with\n paraplegia presents for evaluation.\n\n TECHNIQUE: Prior to the exam informed consent was obtained from the patient\n after explaining the risks, indications, and alternative management. Risks\n explained include infection, bleeding, paralysis, injury to the spinal cord\n and/or nerves, headache, injury to blood vessels, and allergic reaction to\n contrast material.\n\n The patient was brought to the fluoroscopic suite and placed on the\n fluoroscopic table in the prone position. Prior to the start of the\n procedure, a timeout was performed to confirm the patient's identity, using\n two patient identifiers and the procedure to be performed. Access to the\n lumbar subarachnoid space at the L3/4 level was obtained with a 22 gauge\n spinal needle under local anesthesia using 1% lidocaine with aseptic\n precautions. Approximately 12 cc of CSF was collected. Subsequently,\n approximately 7 cc of ISOVUE-300 EM was gently infused into the subarachnoid\n space.\n\n The patient tolerated the procedure well without any immediate post-procedure\n related complication. The patient was subsequently sent back to the emergency\n department with post-procedure orders.\n\n FINDINGS: Contrast flowed readily from the injected level (L3/4) through the\n lumbar spine and extending cephalad to the thoracic spine. There is complete\n block of contrast material at the thoracic vertebral body level. The post-\n myelogram CT of the thoracic and cervical spine reconfirmed that there is\n complete block of contrast within the subarachnoid space at the T4/5 level. A\n cisternal puncture was not performed since the patient does not have a recent\n MRI available for assessment of cisternal space and vasculature within the\n cisternal space.\n\n IMPRESSION: Successful fluoroscopic guided lumbar myelogram.\n\n CSF samples were given to the neurology resident for routine laboratory\n analysis.\n (Over)\n\n 9:06 AM\n MYELOGRAM Clip # \n Reason: Please obtain CSF for diagnostic studies and myelogram to as\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n Contrast: NON IONIC Amt: 7\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Myelogram demonstrates complete block at the T4/5 vertebral body level.\n\n Cisternal access myelogram was not performed since the patient has no recent\n MRI to assess the cisternal space. CT of the C spine raises a questionable\n vessel in the cisternal space.\n\n\n These findings were discussed with Dr. at the time of the\n examination.\n\n Dr. , interventional neuroradiology attending, was present and supervised\n the entire procedure.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2186-07-16 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 971718, "text": " 2:40 PM\n T-SPINE IN O.R.; -77 BY DIFFERENT PHYSICIAN # \n Reason: T4 LAMINECTOMY\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n FINAL REPORT\n Thoracic spine one view, .\n\n CLINICAL INFORMATION: T4 laminectomy.\n\n Comparison is made to the prior study of the same day at 01:11 hours.\n\n FINDINGS:\n\n Again noted is an esophageal stent. The patient is intubated.\n\n Clamps positioned over the T2 spinous process.\n\n IMPRESSION: Intraoperative film as above.\n\n cmy\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2186-07-16 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 971700, "text": " 11:29 AM\n CT C-SPINE W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: obstruction?\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with esophageal cancer and spinal shock\n REASON FOR THIS EXAMINATION:\n obstruction?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old man with esophageal cancer and spinal shock. Question\n obstruction.\n\n CT C-SPINE WITHOUT CONTRAST: Comparison is made to 9:36 a.m. today. There\n essentially is no interval change. Multilevel degenerative changes between C5\n and C7 are again noted. CT is not able to provide intrathecal detail\n comparable to MRI. The visualized outline of the thecal sac as far as it can\n be evaluated from the level of C1 to C5 appears unremarkable, without evidence\n of external compression.\n\n IMPRESSION: No interval change compared to two hours earlier today.\n Multilevel degenerative changes between C5 and C7. No evidence of cord\n compression between C1 and C5.\n\n" }, { "category": "Radiology", "chartdate": "2186-07-16 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 971701, "text": " 11:30 AM\n CT T-SPINE W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: obstruction?\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with esophageal cancer and spinal shock\n REASON FOR THIS EXAMINATION:\n obstruction?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old male patient with esophageal cancer and spinal cord\n shock. Evaluate for spinal cord obstruction.\n\n TECHNIQUE: After fluoroscopic guided spine myelogram, the patient was brought\n to the CT scanner. 3.75-mm axial images through the thoracic spine from T1 to\n the L1 vertebral body were obtained. Sagittal and coronal reformatted images\n provided.\n\n FINDINGS: At the level of the T5 vertebral body, there is total cutoff of the\n cepphald flow of the intrathecal contrast. There is effacement of the CSF\n space around the cord superior to this level. There is soft tissue density in\n the epidural space at the T4/T5 level. Given that the patient has a history\n of esophageal cancer, this could represent metastatic spread into the epidural\n space with spinal cord compression.\n\n There is thickening of the esophagus above the esophageal stent with soft\n tissue filling defects within the esophagus. This is at approximately the T4\n level. There is thickening of the paraspinal soft tissues at this level. This\n could represent spread of the esophageal tumor. However, other etiologies are\n not excluded. There is air within the spinal canal at the T4 and T5 level.\n This is of uncertain etiology, could be due to the presence of an infectious\n process such as an abscess.\n\n The visualized bony structures, however, are within normal limits.\n\n There is a 9-mm irregular opacity in the superior segment of the right lower\n lobe, which could represent of a focal area of atelectasis. However, given\n his history, a metastatic lesion cannot be excluded. A chest CT scan is\n recommended.\n\n IMPRESSION:\n 1. Total cutoff of flow of the intrathecal contrast at the T5 vertebral body\n level with effacement of the CSF space and epidural soft tissue density. The\n findings are consistent with spinal cord compression. Given his history of\n esophageal CA, this could represent metastatic disease.\n 2. Air in the spinal canal of unclear etiology, other etiologies including\n necrotic neoplasm vs infection cannot be excluded.\n 3. Irregular density in the superior segment of the right lower lobe, which\n could represent a focal area of atelectasis or a neoplastic process. Full\n chest CT scan recommended.\n\n (Over)\n\n 11:30 AM\n CT T-SPINE W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: obstruction?\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n" }, { "category": "Radiology", "chartdate": "2186-07-18 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 971965, "text": " 10:47 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess cardiac sillhouette\n Admitting Diagnosis: LOWER EXTREMITY WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with esophageal CA and spinal shock, new hypoxia and\n hypotension\n REASON FOR THIS EXAMINATION:\n assess cardiac sillhouette\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Esophageal cancer and spinal shock, new hypoxia and hypertension;\n assess cardiac silhouette. Study read at time of transmission.\n\n COMPARISON: 9:43 a.m.\n\n CHEST, SINGLE VIEW: Dramatic increase in left lower lobe atelectasis with\n obliteration of the left hemidiaphragmatic silhouette and decrease in aerated\n lung volume. Associated consolidation or effusion cannot be appreciated in\n this single view. Esophageal stent is seen in unchanged position. Persistent\n cardiomegaly. The right lung appears grossly clear. There is no\n pneumothorax.\n\n IMPRESSION:\n\n Interval marked worsening of left lung atelectasis/collapse. These changes\n may relate to mucous plugging.\n\n At the time of dictation, there had been interval resolution of the left lung\n atelectasis/collapse.\n\n" }, { "category": "Nursing/other", "chartdate": "2186-07-21 00:00:00.000", "description": "Report", "row_id": 1640463, "text": "7pm-7am nsg progress notes\n\n51 y/o male with PMH of Ca esophagus s/p chemo and radiation presented OSH with LE weakness also has PMH of suicide attempt in 93 GERD,HTN,MI in96 and 97 and former ETOH.\n\nCVS;HR 95-110NSR/ST no ectopy NBP 100-120/60-75 pedal pulses are palpable.Two PIV on each hand and single lumen PICC line on rt hand remains patent.\n\n\nRESP;On NC and Hiflow O2 50% easily desats t0 low 80,s when mask taken off.RR 22-28 very weak cough unable bringout sputum,breathing efforts were laboured at the beginning of the shift,chest PT on rt side was given refused to do suction.O2 sats are 80-98 LS are diminished all over Chest X-Ray was taken during this episode rt side looks collapsed.Refused for Chest PT inspite of explaining saying that he needs to sleep and dont disturb.\n\n\nNEURO;Alert and oriented moves upper extrimities but not lower,refuses for care and medications.Medicated once at night for pain(percocet PO)\n\nGI;Abdomen soft BS+ on oral diet, but intake is poor. No bowel movement at this shift.\n\nGU;Voiding via foley catheter output was low at the beginning of the shift MD was informed output remained stable after that.\n\nID;Afebrile on IV Ceftriaxone and PO flalgy.\n\nSocial;No contact from family at this shift\n\nPLAN;Chest PT and OOB\nSupport pt and family\nPain management;Encourage cough& deep breath\nMonitor vital signs/resp status/u/o\n?Transfer to hospital\nCode Status;DNR/DNI\n" }, { "category": "Nursing/other", "chartdate": "2186-07-21 00:00:00.000", "description": "Report", "row_id": 1640464, "text": "RESP CARE: Pt recieved at start of shift on 6 lpm NC, 50% high flow aerosol mask. 02 sats dropped to mid to high 80s when pt lying on R side which he preferred.. In-exsufflator rx attempted with pt x3 but he did not cooperate. Nebs given with alb/atr, tol well. CXR revealed complete white-out of R lung. Pt repositioned and remained in semi fowlers position most of the noc, slept well with 02 sats 97-99% on 6 lpm nc/100% high flow mask. Weak ineffective cough notedbut is able to raise small amts thick white with small yellow plugs. Encourage DB/C. Attempt in-exsufflator again this am.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-21 00:00:00.000", "description": "Report", "row_id": 1640465, "text": "Micu nursing note 7-1600\npt scheduled to be transfered to rehad at 1630\n\nneuro: Pt awake and alert able to follow commands, refusing meds all day except for pain meds, refusing any personel care\npt moving arms no movement in legs, neck incision line d/I with steri strips over area\nCv pt stable hemodynamically\nResp pt on high flow plus 6l n/c lungs sounds course LUL and decreased in bases, pt has cough but is non productive\nGi abd soft non tender. taken small amounts of food, no stool\nGU foley in place passing dark yellow urine 20-40 cc hr\nR ac picc intact flush prior to transfer\nId pt afebrile\nA/P transfere to rehab no plans to readmit to hospital, pt is dnr and I would suspect that he will be made cmo in the future.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-20 00:00:00.000", "description": "Report", "row_id": 1640460, "text": "Nursing Progress Note:\nALLERGIES: COCAINE\n\nDNR/DNI\n\nNEURO: pt sleeping most of shift, but easily arousable, makinf needs known; percocet 1 tab tonight with good effect, neck and abd pain ; moves upper extremities, no movement in lower; +CSM UE, LE's has feeling bilateraly below hips anterior and posterior; PERL, pupils 3mm and brisk bilateraly; no seizure activity\n\nCV: SBP 93-135; HR NSR/ST no ectopty; rec'd fluid bolus x1 for HR tachy up to 142, and BP to 90's, no chnage in BP post-bolus but HR now 100; no edema noted; no CP; am lytes per careview; +pedal/radial pulses to plalpation\n\nRESP: early in evening pt having difficulty maintaining sat, with 100% and NC 4L, satting in high 80's, with CPT and CDB; overnight while sleeping has beens able to maintain sats 94-100 on and nc; tolerating CPT q4hrs; able to mobilize some secretions, expectorating thick clear sputum; rr 20-24\n\nGI: +BS, no stools; abd soft non-tender non-distended; nausea this evening, rec'd zofran x1 with relief; soft solids with poor po intake\n\nGU: foley in place; draining adequate amt clear yellow urine, no clots this shift\n\nSKIN: post cerv incision cdi with steris and dsd\n\nID: cont on ceftriaxone and flagyl PO; afeb; WBC's pending\n\nACCESS: PIV x2 WNL and SL PICC WNL\n\nPOC: psych consult in am and ? palliative care consult; cont aggressive pulm toileting and wean O2 as tolerated; ; ? transfer to Hosp where pt gets care/primary ONC team there\n" }, { "category": "Nursing/other", "chartdate": "2186-07-20 00:00:00.000", "description": "Report", "row_id": 1640461, "text": "Resp. Care Note\nPt followed for Albuterol and Atrovent/SVN with mask. BS with decreased and slightly coarse aeration over R. Weak cough. Inexsufflator started with some improvement in cough, but was non- prod. Will cont to follow as tolerated. O2 at 6L NP and High flow neb currently at 50%. FiO2 titrated down from 96% and is maintaining sats 96-97%. Cont to wean FiO2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-20 00:00:00.000", "description": "Report", "row_id": 1640462, "text": "MICU7 RN REPORT 0700-1900\nEVENTS: PSYCHO AND PALLIATIVE AND PT CONSULT.\n\nNEURO: PT ALERT AND ORIENTED. PSYCHO AND PALLIATIVE CONSULT . PT CLAIMS NO SUICIDAL IDEATION @ PRESENT. PATIENT WANTS TO EAT AND WALK. ONCOLOGIST VISTED AND SAID PROGNOSIS IS POOR. UE WITH NORMAL STRENGTH. LE NO MOVEMENT BUT PATIENT SAID HE HAS SENSATION. RECEIVED PERCOCET X2.\n\nCV: HR 80-110 NSR. NO ECTOPI. SBP 90-120. HYPOTENSIVE EPISODE NOTED WHILE SLEEPING. PP+, PICC LINE AND PIV PATENT.\n\nRESP: RECEIVED PT ON AT 15L AND NC AT 6L. AT 1100 O2 WEANED TO COOL NEB MASK AT 60% WITH 6L NC. FREQ. CHEST PT AND ATTEMPTED TO IMPROVE HIS COUGH BY USING INSUFILATOR WITH BETTER RESPONSE. AT 1700 COOL NEB REDUCED TO 50%. SPO2 95%. LS COARSE AND DIMINISHED. NO SOB.\n\nGI- ABD SOFT. BS X4 BM X1 LOOSE. ABLE TO TAKE LIQUIDS IN SMALL AMOUNTS. NO NAUSEA OR VOMITING.\n\nGU: FOLEY DRAINS CLEAR YELLOW URINE AT 30-60ML/HR.\n\nSKIN; S/P SURGICAL SITE DRESSING DRY AND INTACT. NO OTHER SKIN BREAKDOWN.\n\nSOCIAL; DNR, DNI. FAMILY CALLED AND FRIEND .\n\nPLAN; WEAN O2 TO MAINTAIN SAT OF > 90%\n DIET AS HE TOLERATES.\n CHEST \n AFTER PT RESPIRATORY STATUS IMPROVES PT WILL BE TRANSFERRED TO HOSPITAL FOR PALLITIVE CARE\n PAIN MANAGEMENT\n PT CONSULT DONE TO MOBILIZE THE PATINET TO CHAIR\n\nS\n" }, { "category": "Nursing/other", "chartdate": "2186-07-18 00:00:00.000", "description": "Report", "row_id": 1640454, "text": "NURSING ADMISSION AND PROGRESS NOTE 1030-1900\nREPORT RECEIVED FROM 5. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A 51 Y/O M WITH PMH SIGNIFICANT FOR ESOPHAGEAL CA S/P CHEMO, ESOPHADEAL STENTING S/P RADIATION, SUICIDE ATTEMPT IN WITH CIRCULAR SAW- SURGICALLY REPAIRED INJURY WITH LT EYE PTOSIS AND BRAIN CLIPS, GERD, HTN, ETOH, COCAINE, MARIJUANA ABUSE WHO INITIALLY PRESENTED TO AN OSH ON FOR EVALUATION OF NEW ONSET LE PARALYSIS. PT REPORTED THAT HE HAD UPPER BACK PAIN FOR 2 DAYS PRIOR TO PRESENTATION. TX TO FOR FURTHER MANAGEMENT- CT SCAN SIGNIFICANT FOR EPIDURAL ABCESS AND BLOCKAGE- EMERGENTLY BROUGHT TO OR FOR WASHOUT, DEBRIDEMENT AND T2-T5 LAMINECTOMY. HAD BEEN ON 5 UNTIL WHEN HE HAD EPISODE OF DESATURATION TO 70'S- TX TO MICU FOR FURTHER MANAGEMENT. DNR/DNI.\n\nNEURO: PT ALERT AND ORIENTED X 3. PERRLA, 4/BRISK. AFEBRILE. SPEECH CLEAR- NOTED TO HAVE LT EYELID PTOSIS- BASELINE FROM PREVIOUS SURGERY. ABLE TO FOLLOW COMMANDS WITHOUT DIFFICULTY- HAS NORMAL STRENGTH TO BILATERAL UPPER EXTREMITIES BUT PARALYZED TO BILATERAL LOWER EXTREMITIES. NO SEIZURE ACTIVITY NOTED. PT IS HAVING DIFFICULTY COPING WITH CURRENT STATE OF HEALTH- SOCIAL WORK CONSULT OBTAINED- NEED EVENTUAL PSYCH EVAL. NECK DRESSING IS C/D/I. PT FIT FOR THORACIC ORTHOTICS- CURRENTLY AT BEDSIDE.\n\nRR: BBS= UPON INITIAL ARRIVAL TO PT NOTED TO HAVE COARSE SOUNDS TO BILATERAL UPPER LOBES AND DIMINISHED TO BILATERAL BASES- HAS HAD INTERMITTENT PERIODS OF WHEEZING- IS NOW CURRENTLY ORDERED FOR NEBULIZERS WITH THERAPEUTIC RESPONSE. PT IS UNABLE TO MOBILIZE SECRETIONS AND HAS BEEN REQUIRING FAIRLY CHEST PT. HAS BEEN ABLE TO EXPECTORATE CLEAR, WHITE MUCUS AFTER CHEST PERCUSSION. INITIALLY REQUIRED 100% NRB- CURRENTLY ON 6L NC. PT HAS VERY LITTLE RESERVE AND WILL DECOMPENSATE TO THE LOW 80'S WHEN OVERSTIMULATED- AS SUCH, HAVE BEEN LIMITING FAMILY VISITS. WHEN PT IS AT SP02 > OR = TO 95%. UNABLE TO LAY COMPLETELY FLAT. WOULD LIKE TO OBTAIN CHEST CT, HOWEVER, AS OF YET, PT IS UNABLE TO TOLERATE- CURRENTLY ON HOLD-MICU TEAM IS AWARE. CURRENTLY PT ONLY C/O FEELING CONGESTED AND NOT SOB.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR- ST, HR 90-100'S WITH NO SIGNS OF ECTOPY NOTED. DENIES ANY CHEST PAIN. WEAKLY PALPABLE PULSES TO BILATERAL DORSALIS AND RADIALS. ECHO OBTAINED THIS AFTERNOON- QUESTION OF PERICARDIAL EFFUSION- CARDIOLOGY CONSULTED. NO TAP AS OF YET. PT CURRENTLY HAS #20 PIV TO LT FA AND #18PIV OBTAINED BY THIS RN TO RT HAND.\n\nGI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER. DIET ADVANCED TO SOFT FOODS AS PT WILL TOLERATE. NO C/O N,V,D. PASSING FLATUS. NO BM THIS SHIFT.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. PT NOTED TO HAVE SOME SCANT AMOUNTS OF BLOODY OOZING FROM YESTERDAY PT ATTEMPTED TO SELF DC HIS FOLEY. UROLOGY CONSULTED. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS- SURGICAL INCISION TO NECK HAS CLEAN, DRY AND IN\n" }, { "category": "Nursing/other", "chartdate": "2186-07-18 00:00:00.000", "description": "Report", "row_id": 1640455, "text": "NURSING ADMISSION AND PROGRESS NOTE 1030-1900\n(Continued)\nTACT DRESSING.\n\nSOCIAL: VERY LARGE AND INVOLVED FAMILY. WITH PT AND HCP THAT PT IS A DNR/DNI. ALL QUESTIONS ANSWERED BY MD.\n\nPLAN: CARDIOLOGY, NEUROLOGY FOLLOWING. VERY TENUOUS RESPIRATORY STATS- LACKS RESERVE AND IS NEED OF FREQUENT AND CHEST PT TO CLEAR SECRETIONS. HIGH RISK FOR WITHDRAWAL GIVEN SOCIAL HABITS. CURRENTLY HAS NICOTINE PATCH ON- SHOULD BE ON CIWA SCALE. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-07-18 00:00:00.000", "description": "Report", "row_id": 1640456, "text": "Respiratory Care\nPatient emergently transferred from FAAR 5 to MICU-7 while into respiratory distress, SPO2 was in the lower 70s on NRB, patient sounded very congested, had cardiac echo, ultrasound, chest xray, refused NTS, mask ventilation was unsuccessful, patient was then put on NRB +6L nasal cannula, has then been weaned from NRB is nor on 6L nasal cannula, SPO2 drops when patient is stimulated, vent left with mask at bedside in case of potential need of NIV overnight, will continue to be followed.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-19 00:00:00.000", "description": "Report", "row_id": 1640457, "text": "Nursing Progress Note:\nDNR/DNI\n\nALLERGIES: COCAINE (N/V)\n\nEVENTS: pt down to CT of chest during day, found shift of mediastinal structures to left d/t partial lung collapse secretions in left mainstem bronchus; beginning of shift, pt agitated, refusing , taking off repeatedly, desatting to low 80's, given valium 5mg; switched to Hi Flow Neb with NC and recovered sats to high 90's; afterwards placed on left side, where pt again desatted to low 80's, tachy to 120's, put back on 6L NC with 100% , taking several minutes to recover to high 90's at rest\n\nNEURO: pt alert and oriented x3, sleeping occasionally during night; c/o pain \"all over\", percocets ordered and given 1-2 tabs with good effect; left eye ptosis at baseline; pupils 3\\mm and brisk bilaterally, PERL; +CSM upper extremities; lower extremities, no movement, reports increased sensation, +sensation to upper and lower legs, ant and posterior; agitated beginning of shift, refusing to wear , stating \" I just want to die\", \"Give me cyanide or rat poison\", \"I give up, I don't want to live anymore\", \"put me on my stomach so I'll stop breathing\", pt declined clergy and offer to family, md aware; pt's safety maintained, visible from RN station; suggested to md that pt have 1:1 sitter for safety and to discourage taking off mask/nasal cannula but not ordered; CIWA scale 0-3, given valium 5mg x1 in the evening with good effect; no seizure activity; pt frequently refusing nursing care i.e. bedbath, chest PT, mask\n\nCV: SBP 107-126, MAPs >60; HR NSR/ST no ectopy, 75-112; tachy up to 120-130's when desatting or left side lying; +pedal/radial pulses to palpation; no edema noted; lytes per Careview; some bleeding from urethra noted, HCT stable; no CP; pneumoboots and heparin prophylactically\n\nRESP: LS coarse to rhonchorous throughout; satting low 80's to 100%, now on 100% and 6LNC, satting 100%; after activity, pt to high 80's to low 90's, taking several minutes to recover sats; CPT as allowed by pt; pt expectorating moderate amt thiock clear secretions; RR up to 38 with activity, otherwise 20-30\n\nGI: +BS, no stools; and soft, non-tender, non-distended; speech/swallow on , allowed soft solids and thin liqs; poor PO intake; pt will take po meds crushed and swallow with water\n\nGI: foley in place, draining clear yellow urine with old brown clots d/t traumatic insertion of foley per admission notes; sm amt bloody drainage from urethra tonight; U/O 50-120cc/hr\n\nSKIN: back incision cdi with steri, DSD intact, no drainage\n\nID: cont on flagyl/cipro/ceftriaxone for spinal infection; afeb tmax 99; WBC's 9.6\n\nACCESS: PIVx2 WNL\n\nPOC: cont pain mgt; aggressive pulm toileting as pt will allow and neb tx for mucous plugging; maintain O2 >90%; maintain pt safety; cont abx; ? pericardiocentesis when pt more stable; TLSO brace when OOB; cont nicotine patch\n" }, { "category": "Nursing/other", "chartdate": "2186-07-19 00:00:00.000", "description": "Report", "row_id": 1640458, "text": "Resp. Care:\n Pt. with desat's to 80's last eve. Rx'd with albuterol neb. for coarse BS, and changed to hi- neb. vs. mask. Tol. fairly well for some of eve, but eventually needed to be switched back to mask for pt. comfort. Occas. takes mask off with resultant immed. drop in sA02 to 80's. This also occurs with any movement, but Recovers in a few minutes once mask replaced. 6 l/m nc also remains on under mask. Will cont. to follow pt. for high 02 requirements and prn albuterol nebs.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-19 00:00:00.000", "description": "Report", "row_id": 1640459, "text": "NURSING PROGRESS NOTE 0700-1900\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT IN BETTER SPIRITS THIS SHIFT. NOT SO QUICK TO PURSUE DEATH DECREE. SOCIAL WORK PT BE DEPRESSED- POSSIBLE PSYCH CONSULT. AFEBRILE. NO SEIZURE ACTIVITY NOTED. PT HAS HAD 3 OUT OF 10 PAIN- MANAGED WITH PERCOCET. SPEECH CLEAR. FOLLOWS COMMANDS WITHOUT DIFFICULTY. UNABLE TO MOVE LOWER EXTREMITIES ALTHOUGH PT CLAIMS THAT HE THINKS HIS \"FEELING IS GETTING BETTER\".\n\nRR: BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS AND DIMINISHED TO BILATERAL BASES. BILATERAL CHEST EXPANSION NOTED. PT'S OXYGEN REQUIREMENT HAS BEEN TEMPERMENTAL- AT TIMES- ABLE TO WEAN TO 2LNC, OTHER TIMES PT REQUIRES HI FLOW MASK. SP02 WILL OCCASIONALLY STILL DIP DOWN TO THE HIGH 80'S AND IT TAKES A FEW MINUTES FOR PT TO RECUPERATE TO HIS USUAL 92-95%. WEAK COUGH EFFORT- ATTEMPTS TO EXPECTORATE WITH MODERATE SUCCESS. CONTINUING WITH AGGRESSIVE CHEST PT. DENIES ANY SOB AND STATES THAT HE FEELS HIS CONGESTION IS BETTER. MUCH IMPROVED CXR.\n\nCV: S1 AND S2 AS PER AUSCULTATION. HR 90-110'S. NO SIGNS OF ECTOPY NOTED. DENIES ANY CHEST PAIN. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE EPISODES NOTED. WEAKLY PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT HAD PICC LINE PLCMT TO LT ARM- PROPER PLCMT VERIFIED VIA CXR- OKAY TO USE AS MD.\n\nGI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER. NO BM THIS SHIFT- CONTINUES ON BOWEL REGIMEN. ABLE TO TOLERATE SOME SOFT FOODS TODAY- CONSUMED A SMALL PORTION OF HIS BREAKFAST AND HIS LUNCH. HIGH RISK FOR ASPIRATION. NO C/O N,V,D.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS. NECK INCISION DRESSING IS CLEAN, DRY AND INTACT.\n\nSOCIAL: FAMILY IN TO VISIT- TOUCHED BASE WITH DR. . NO ISSUES.\n\nPLAN: SOCIAL WORK TO CONTINUE TO FOLLOW, PSYCH TO CONSULT. CONTINUE TO MONITOR RESPIRATORY STATUS, AGGRESSIVE CHEST PT. POSSIBLE C/O TO FLOOR OR TRANSFER BACK TO HOSPITAL TOMORROW. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Echo", "chartdate": "2186-07-18 00:00:00.000", "description": "Report", "row_id": 99414, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. ?tamponade..\nHR (bpm): 99\nStatus: Inpatient\nDate/Time: at 10:52\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPERICARDIUM: Moderate pericardial effusion. Brief RA diastolic collapse.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThere is a moderate sized pericardial effusion most prominent anterior to the\nright atrium with brief right atrial diastolic collapse. A promient echogenic\narea is seen overlying the right ventricular free wall which likely represents\nepicardial fat (cannot exclude thrombus or tumor if this is clinically\nsugested). There is but no right ventricular diastolic collapse with\nrelatively minimal fluid anterior to the right ventricle. There is mild\neccentuation of transmitral Doppler E wave suggesting increased pericardial\npressure.\nSerial evaluation is suggested.\n\n\n" }, { "category": "ECG", "chartdate": "2186-07-18 00:00:00.000", "description": "Report", "row_id": 282571, "text": "Sinus tachycardia. Borderline low QRS voltage in limb leads. Delayed\nanterior precordial R wave progression. Cannot exclude prior anterior\nmyocardial infarct. No previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2116-01-03 00:00:00.000", "description": "Report", "row_id": 112668, "text": "Sinus rhythm. Left axis deviation. Probable prior inferior myocardial\ninfarction. Poor R wave progression. Diffuse low QRS voltage. Non-specific\nprecordial T wave changes. Compared to the previous tracing of the\nventricular premature beats are absent. T wave inversion is more pronounced\nin leads V1-V3.\n\n" }, { "category": "ECG", "chartdate": "2115-12-31 00:00:00.000", "description": "Report", "row_id": 112669, "text": "Sinus rhythm. Frequent ventricular premature beats. Diffuse T wave changes that\nare non-specific. Probable old inferior wall myocardial infarction. Compared to\nthe previous tracing of there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2115-12-30 00:00:00.000", "description": "Report", "row_id": 112670, "text": "Sinus rhythm. Occasional ventricular premature beats. P-R interval\nprolongation. Left axis deviation. Probable old inferior myocardial infarction.\nCompared to the previous tracing of ventricular premature beats are\nnew. Otherwise, no other significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2116-01-10 00:00:00.000", "description": "Report", "row_id": 112667, "text": "Atrial pacing and a single ventricular premature beat. Pacing artifact\nis only well seen in the precordial leads. Since the previous tracing the rate\nis identical it may be atrial pacing throughout. Since the previous tracing\nthe atrial rate is less. T wave abnormalities are less prominent. Clinical\ncorrelation is suggested.\n\n" }, { "category": "Physician ", "chartdate": "2116-01-07 00:00:00.000", "description": "Intensivist Note", "row_id": 401349, "text": "TITLE:\n SICU\n HPI:\n 86y M p/w severe abdominal pain, n/v found to have high-grade SBO with\n potential internal hernia on abdominal CT scan. He was managed\n conservatively initially with NGT decompression and serial abdominal\n exams. The following day began to complain of increasing abdominal pain\n and was focally tender with guarding in RLQ. Pt was taken to the OR for\n ex-lap and lysis of adhesions on . Post-operatively in PACU,\n noted to have WCT at rate of ~ 170 (SVT with aberrancy vs VT)with\n associated drop in SBP to 60s. Broke spontaneously and did not receive\n ICD shock. EP interrogated the device which was reportedly functioning\n appropriately. Pt then admitted to floors. Hospital course c/b episode\n of AMS resolved with prn haldol; bilious emesis with subsequent NGT\n placement with copious bilious outpt. Pt also with low UOP requiring\n several IVF boluses on the floors. On , pt with respiratory\n distress and copious secretions. Pt transferred to the SICU for further\n management.\n Chief complaint:\n respiratory distress\n PMHx:\n -- CAD s/p MI x2, RCA stent \n -- s/p AICD placement in (due to NSVT and inducible\n monomorphic VT)\n -- HTN\n -- CHF (EF 55% in with diastolic dysfunction)\n -- DM2\n -- hyperlipidemia\n -- history of TIAs\n -- h/o internal hemorrhoids (bleeding on anoscopy in )\n -- colonoscopy in with hyperplastic polyp and diverticulosis\n -- irritable bowel syndrome,\n -- prostate CA s/p TURP ('s) and radiation proctitis\n -- BPH\n -- CKD\n -- hyperparathyroidism\n -- hypothyroidism\n -- s/p cataract surgery R eye\n -- h/o spinal stenosis and radiculopathy\n Current medications:\n 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing Order date:\n @ 1700\n 9. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1517\n 2. Calcium Gluconate IV Sliding Scale Order date: @ 1636\n 10. Levothyroxine Sodium 62.5 mcg IV DAILY Order date: @ 1521\n 3. Calcitriol 0.25 mcg IV 3X/WEEK (TU,TH,SA) Order date: @ 1728\n 11. Magnesium Sulfate IV Sliding Scale Order date: @ 1636\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1517\n 12. Metoprolol Tartrate 5 mg IV Q4H Order date: @ 1517\n 5. Dipyridamole-Aspirin 1 CAP PO BID Order date: @ 1700\n 13. Morphine Sulfate 1-2 mg IV Q4H:PRN pain Order date: @ 1700\n 6. Furosemide 40 mg IV ONCE Duration: 1 Doses Order date: @ 1435\n 14. Pantoprazole 40 mg IV Q24H Order date: @ 1700\n 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 1517\n 15. Potassium Chloride IV Sliding Scale Order date: @ 1636\n 8. Heparin 5000 UNIT SC TID Order date: @ 1629\n 16. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1636\n 24 Hour Events:\n respiratory distress. ?aspiration. Transferred to SICU. s/p aggressive\n suctioning. Given lasix 40mg IV x1. +flatus. NGT removed. Occassional\n runs of NSVT without effect on SBP, asymptomatic. Electrolytes checked\n and repleted as needed.\n Allergies:\n Penicillins\n Unknown;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:45 PM\n Pantoprazole (Protonix) - 08:11 PM\n Heparin Sodium (Prophylaxis) - 12:43 AM\n Morphine Sulfate - 03:00 AM\n Metoprolol - 04:28 AM\n Other medications:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 62 (61 - 91) bpm\n BP: 132/62(80) {108/47(60) - 155/79(94)} mmHg\n RR: 16 (13 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.2 kg (admission): 84.8 kg\n Total In:\n 145 mL\n 134 mL\n PO:\n Tube feeding:\n IV Fluid:\n 145 mL\n 134 mL\n Blood products:\n Total out:\n 2,570 mL\n 1,100 mL\n Urine:\n 2,570 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,425 mL\n -966 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: ///32/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 231 K/uL\n 11.0 g/dL\n 88 mg/dL\n 1.3 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 18 mg/dL\n 102 mEq/L\n 142 mEq/L\n 33.4 %\n 10.4 K/uL\n [image002.jpg]\n 10:00 PM\n 03:16 AM\n WBC\n 10.4\n Hct\n 33.4\n Plt\n 231\n Creatinine\n 1.2\n 1.3\n Glucose\n 87\n 88\n Other labs: Ca:8.9 mg/dL, Mg:2.8 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR - decrease in the pulmonary vascular congestion with\n persistent bibasilar atelectasis. Increasing opacification at the left\n base could reflect worsening atelectasis or increasing pleural\n effusion.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ASSESSMENT: 86M with SBO, s/p exlap, LOA now with respiratory distress\n ?aspiration.\n Neurologic:\n -- AOx3, no focal deficits\n -- consider prn haldol if patient becomes agitated/confused\n -- morphine prn pain\n Cardiovascular:\n -- hx of MI, CAD, NSVT s/p AICD, CHF\n -- on carvedilol at home. Currently on metoprolol 5mg IV q4h (until can\n resume po meds)\n -- cont aggrenox\n -- occassional episodes of NSVT. Electrolytes checked and repleted as\n needed.\n Pulmonary:\n -- respiratory distress with copious secretions. ?aspiration\n -- encourage Chest PT, IS\n -- likely with pulm effusions. Given lasix 40mg IV x1 to diurese.\n -- albuterol prn\n Gastrointestinal / Abdomen:\n -- +flatus\n -- NGT d/c'ed \n -- Official S&S consulted. (Bedside swallow, pt appears to be\n aspirating)\n -- PPI for GI prophy\n Nutrition: may take sips once eval'ed by S&S\n Renal:\n -- hx of CKD, BPH, prostate CA s/p TURP\n -- condom cath in place. Monitor UOP. Cr 1.3.\n -- (If pt required foley catheter, 14f cudet catheter used in past)\n Hematology:\n -- Hct 33.4\n Endocrine:\n -- hx of DM: RISS. Restart home meds when tolerating po diet\n -- hx of hypothyroidism: cont levothyroxine\n -- hx of hyperparathyroidism secondary to CKD: cont calcitriol\n ID: Afebrile. No ABX at this time. WBC 10.4\n T/L/D: PIVx1, condom cath (consider PICC?)\n Wounds: abdominal incision c/d/i\n Imaging: CXR\n Fluids: heplocked\n Consults: gold west 2 surgery, cardiology\n Billing Diagnosis: respiratory distress\n Prophylaxis:\n DVT: aggrenox, SQH\n Stress ulcer: PPI\n VAP bundle: n/a\n Comments: ICU consent completed\n Communication: Son (h), (w),\n (c), (c)\n Code status:FULL\n Disposition:SICU\n Time spent: 35\n" }, { "category": "Physician ", "chartdate": "2116-01-07 00:00:00.000", "description": "Intensivist Note", "row_id": 401373, "text": "TITLE:\n SICU\n HPI:\n 86y M p/w severe abdominal pain, n/v found to have high-grade SBO with\n potential internal hernia on abdominal CT scan. He was managed\n conservatively initially with NGT decompression and serial abdominal\n exams. The following day began to complain of increasing abdominal pain\n and was focally tender with guarding in RLQ. Pt was taken to the OR for\n ex-lap and lysis of adhesions on . Post-operatively in PACU,\n noted to have WCT at rate of ~ 170 (SVT with aberrancy vs VT)with\n associated drop in SBP to 60s. Broke spontaneously and did not receive\n ICD shock. EP interrogated the device which was reportedly functioning\n appropriately. Pt then admitted to floors. Hospital course c/b episode\n of AMS resolved with prn haldol; bilious emesis with subsequent NGT\n placement with copious bilious outpt. Pt also with low UOP requiring\n several IVF boluses on the floors. On , pt with respiratory\n distress and copious secretions. Pt transferred to the SICU for further\n management.\n Chief complaint:\n respiratory distress\n PMHx:\n -- CAD s/p MI x2, RCA stent \n -- s/p AICD placement in (due to NSVT and inducible\n monomorphic VT)\n -- HTN\n -- CHF (EF 55% in with diastolic dysfunction)\n -- DM2\n -- hyperlipidemia\n -- history of TIAs\n -- h/o internal hemorrhoids (bleeding on anoscopy in )\n -- colonoscopy in with hyperplastic polyp and diverticulosis\n -- irritable bowel syndrome,\n -- prostate CA s/p TURP ('s) and radiation proctitis\n -- BPH\n -- CKD\n -- hyperparathyroidism\n -- hypothyroidism\n -- s/p cataract surgery R eye\n -- h/o spinal stenosis and radiculopathy\n Current medications:\n 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing Order date:\n @ 1700\n 9. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1517\n 2. Calcium Gluconate IV Sliding Scale Order date: @ 1636\n 10. Levothyroxine Sodium 62.5 mcg IV DAILY Order date: @ 1521\n 3. Calcitriol 0.25 mcg IV 3X/WEEK (TU,TH,SA) Order date: @ 1728\n 11. Magnesium Sulfate IV Sliding Scale Order date: @ 1636\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1517\n 12. Metoprolol Tartrate 5 mg IV Q4H Order date: @ 1517\n 5. Dipyridamole-Aspirin 1 CAP PO BID Order date: @ 1700\n 13. Morphine Sulfate 1-2 mg IV Q4H:PRN pain Order date: @ 1700\n 6. Furosemide 40 mg IV ONCE Duration: 1 Doses Order date: @ 1435\n 14. Pantoprazole 40 mg IV Q24H Order date: @ 1700\n 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 1517\n 15. Potassium Chloride IV Sliding Scale Order date: @ 1636\n 8. Heparin 5000 UNIT SC TID Order date: @ 1629\n 16. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1636\n 24 Hour Events:\n respiratory distress. ?aspiration. Transferred to SICU. s/p aggressive\n suctioning. Given lasix 40mg IV x1. +flatus. NGT removed. Occassional\n runs of NSVT without effect on SBP, asymptomatic. Electrolytes checked\n and repleted as needed.\n Allergies:\n Penicillins\n Unknown;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:45 PM\n Pantoprazole (Protonix) - 08:11 PM\n Heparin Sodium (Prophylaxis) - 12:43 AM\n Morphine Sulfate - 03:00 AM\n Metoprolol - 04:28 AM\n Other medications:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 62 (61 - 91) bpm\n BP: 132/62(80) {108/47(60) - 155/79(94)} mmHg\n RR: 16 (13 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.2 kg (admission): 84.8 kg\n Total In:\n 145 mL\n 134 mL\n PO:\n Tube feeding:\n IV Fluid:\n 145 mL\n 134 mL\n Blood products:\n Total out:\n 2,570 mL\n 1,100 mL\n Urine:\n 2,570 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,425 mL\n -966 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: ///32/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 231 K/uL\n 11.0 g/dL\n 88 mg/dL\n 1.3 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 18 mg/dL\n 102 mEq/L\n 142 mEq/L\n 33.4 %\n 10.4 K/uL\n [image002.jpg]\n 10:00 PM\n 03:16 AM\n WBC\n 10.4\n Hct\n 33.4\n Plt\n 231\n Creatinine\n 1.2\n 1.3\n Glucose\n 87\n 88\n Other labs: Ca:8.9 mg/dL, Mg:2.8 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR - decrease in the pulmonary vascular congestion with\n persistent bibasilar atelectasis. Increasing opacification at the left\n base could reflect worsening atelectasis or increasing pleural\n effusion.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ASSESSMENT: 86M with SBO, s/p exlap, admit to ICU with resp distress,\n now much improved ?aspiration due to hx of vomiting on floor.\n Neurologic:\n -- AOx3, no focal deficits\n -- consider prn haldol if patient becomes agitated/confused\n -- morphine prn pain\n Cardiovascular:\n -- hx of MI, CAD, self terminated NSVT s/p AICD, CHF\n -- on carvedilol at home. Currently on metoprolol 5mg IV q4h (until can\n resume po meds)\n -- cont aggrenox\n -- occassional episodes of NSVT. Electrolytes checked and repleted as\n needed.\n -- EP to report if SVT is new onset or unchanged from preop.\n Pulmonary:\n -- respiratory distress with copious secretions. ?aspiration\n -- encourage Chest PT, IS\n -- likely with pulm effusions. Given lasix 40mg IV x1 to diurese.\n -- albuterol prn\n Subjectively improved\n Gastrointestinal / Abdomen:\n -- +flatus\n -- NGT d/c'ed \n -- Official S&S consulted. (Bedside swallow, pt appears to be\n aspirating)\n -- PPI for GI prophy\n Nutrition: may take sips once eval'ed by S&S\n Dobhoff if doesn\nt pass S&S\n Renal:\n -- hx of CKD, BPH, prostate CA s/p TURP\n -- condom cath in place. Monitor UOP. Cr 1.3.\n -- (If pt required foley catheter, 14f cudet catheter used in past)\n Hematology:\n -- Hct 33.4\n Endocrine:\n -- hx of DM: RISS. Restart home meds when tolerating po diet\n -- hx of hypothyroidism: cont levothyroxine\n -- hx of hyperparathyroidism secondary to CKD: cont calcitriol\n ID: Afebrile. No ABX at this time. WBC 10.4\n T/L/D: PIVx1, condom cath (consider PICC?)\n Wounds: abdominal incision c/d/i\n Imaging: CXR\n Fluids: heplocked\n Consults: gold west 2 surgery, cardiology\n Billing Diagnosis: respiratory distress\n Prophylaxis:\n DVT: aggrenox, SQH\n Stress ulcer: PPI\n VAP bundle: n/a\n Comments: ICU consent completed\n Communication: Son (h), (w),\n (c), (c)\n Code status:FULL\n Disposition:Floor\n Time spent: 35\n" }, { "category": "Rehab Services", "chartdate": "2116-01-07 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 401383, "text": "Subjective:\n \"I want to get things going.\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for patient education\n Updated medical status: Tx to ICU with respiratory distress\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n n/a\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n n/a\n\n\n\n\n\n\n Transfer:\n n/a\n\n\n\n\n\n\n Sit to Stand:\n X 2 reps\n\n\n\n\n T\n\n Ambulation:\n Pushing w/c\n\n\n T\n\n\n\n Stairs:\n n/a\n\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 70\n 146/56\n 93% 4L\n Activity\n Stand\n 92\n /\n 97% 4L\n Recovery\n Sit\n 92\n 137/67\n 97% 4L\n Total distance walked: 150'\n Minutes: 4 min\n Gait: Ambulated pushing w/c x 150' with decreased cadence and step\n length, no LOB, difficulty navigating wheelchair\n Balance: Seated: no LOB with B UE support on armrests of chair\n Standing: no LOB with B UE support and CG\n Education / Communication: Educated patient as to role of PT, benefit\n of ambulation.\n Communicated with RN.\n Other:\n Assessment: Patient shows improved function from previous visit, but\n continues to require moderate assist for sit to stand, and patient\n continues to have a high O2 requirement. Anticipate that patient will\n need rehab on discharge to maximize function and pulmonary status.\n Anticipated Discharge: Rehab\n Plan: Gait training with RW, transfer training, balance training, wean\n O2, DB, PLB, patient education\n RN Recommendations: OOB to chair for meals with mod A x 1; ambulate\n pushing w/c or walker with CG x 1 daily\n Face Time: 11:22\n 11:52\n" }, { "category": "Nursing", "chartdate": "2116-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 401291, "text": "86 y.o. male s/p LOA and SBR for SBO on transferred from 9\n secondary to difficulty with secretions requiring frequent suctioning\n by nursing. Pt with extensive cardiac history and AICD in\n place.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n rhonchorous lung sounds throughout\n fine crackles at bases\n Action:\n Lasix 40 mg IV\n Chest PT\n OOB to chair\n NT suctioned and Yankauer suctioned to induce cough\n humidified o2 on at 35% and NC at 4L NC\n sips water with coughing afterwards- ? aspiration\n Response:\n maintaining o2 sats >96%\n raising thick yellow secretions\n NT suctioned for cream thick secretions with new blood tinge\n 730 cc urine thus far via condom cath\n MD notifed of coughing post liquid- swallow test ordered\n Plan:\n Chest PT, PT OOB\n pulmonary toilet\n wean O2 as tolerated, humidified mask for secretions\n Question need for additional lasix\n place foley with 12 F coude if needs foley placement secondary to hx of\n TURP\n swallow test tomorrow for question of aspiration\n" }, { "category": "Rehab Services", "chartdate": "2116-01-07 00:00:00.000", "description": "Bedside Swallow Evaluation", "row_id": 401379, "text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 86 year old male with a history\nof CAD s/p MI and PCI, nonischemic now with nl EF, sustained\nmonomorphic VT s/p ICD placement, DM, htn, HL, CKD who was\nadmitted to with 1 day of severe abdominal pain,\nnausea and vomiting. He was found to have high-grade SBO with\npotential internal hernia on abdominal CT scan. He was admitted\nto the surgical service and was managed conservatively initially\nwith NGT decompression and serial abdominal exams. Patient\ninitially improved but the following day began to complain of\nincreasing abdominal pain and was focally tender with guarding in\nRLQ. Given his CT findings and worsening exam, he was taken to\nthe OR for ex-lap and lysis of adhesions. However,\npost-operatively in PACU,noted to have WCT at rate of ~ 170 with\nassociated drop in SBP to 60s. Broke spontaneously and did not\nreceive ICD shock. EP interrogated the device which was\nreportedly functioning appropriately. Cardiology consulted\nregarding further management. Per chart, pt noted with coughing\nfollowing trials of thin liquid. We were consulted to evaluate\noral and pharyngeal swallowing function and r/o aspiration when\neating and drinking. RN, pt taking thin liquids this morning\nwith no coughing. Pt reported having a swallowing evaluation in\nthe past due to coughing and choking when eating and drinking.\nRecommendation at that time, per pt, was to refrain from talking\nwhen eating and drinking, but no diet changes were recommended.\nPt reported that he must cut solid foods into small pieces to\nmanage chewing.\nPAST MEDICAL HISTORY:\n# CAD s/p MI x2, s/p 3.5x12mm GFX stent to RCA '\n# CHF\n- h/o nonischemic , 20% on LVgram \n- EF 55% in on TEE with diastolic dysfunction\n# h/o inducible sustained monomorphic VT on EPS (for depressed EF\nand unexplained syncope) s/p ST. AICD placement\n# DM2\n# hyperlipidemia\n# HTN\n# CKD III, BL Cr 1.4\n# hypothyroidism\n# history of TIAs\n# prostate CA s/p TURP ' and radiation proctitis\n# irritable bowel syndrome\n# BPH\n# s/p cataract surgery R eye\n# Secondary hyperparathyroidism\n# Spinal stenosis and radiculopathy\n- followed at Mgmt Ctr for lumbar epidural DepoMedrol\ninjections\n# internal hemorrhoids (bleeding on anoscopy in )\n# hyperplastic polyps and diverticulosis (colonoscopy )\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the chair on the ICU.\nCognition, language, speech, voice:\nPt awake, able to answer basic questions, conversing\nappropriately with SLP though somewhat tangential. Speech was\nWFL. Vocal quality was soft and moderately hoarse.\nTeeth:\nEdentulous, dentures present and in place during trials of solid.\nSecretions:\nDry oral cavity\nORAL MOTOR EXAM:\nTongue protruded midline, lingual strength and ROM were WFL.\nLabial strength and ROM and buccal tone appeared mildly reduced.\nPalatal elevation was WFL. Gag deferred to maintain rapport.\nSWALLOWING ASSESSMENT:\nPt was seen with ice chips, thin liquid (tsp, straw), puree, and\nregular solid.\nPt slow to form labial seal on spoon with mild anterior bolus\nloss of thin liquid from spoon. Bolus manipulation and\nmastication were WFL. Pt able to transition bolus A-P. Mild oral\ncavity residue noted with regular solid, pt able to clear with\nf/up sip of thin liquid. Swallowing trigger and laryngeal\nelevation WFL on palpation. No coughing, choking, throat\nclearing, or changes in vocal quality noted for any PO trials.\nSUMMARY / IMPRESSION:\nPt presents with a functional swallowing mechanism without s/sx\nof aspiration. Recommend PO diet of regular consistency solids\nand thin liquids at this time, pending clearance from medical\nteam.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 7.\nRECOMMENDATIONS:\n1. PO diet of regular consistency solids and thin liquids pending\nmedical clearance.\n2. Pills with thin liquid or puree as tolerated.\n3. Close supervision during meals to assist with feeding\n4. Q4 oral care\n5. Alternate bites and sips to clear oral cavity residue.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CF\nPager #: \n____________________________________\n , M.S., CCC-SLP\nPager #: \nFace time:1000-1015\nTotal time:60 minutes\n [BUTTON Input] (not implemented)_____\n 11:16\n" }, { "category": "Nursing", "chartdate": "2116-01-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 401321, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile. SR in 60s-70s, frequent PVCs/PACs. 20 + beat Vtach vs. WCT\n x2, pt. stable w/SBP in 100-120s w/events. No evidence of AICD firing.\n SICU HO aware. Lung sounds w/rhonchi, dim to bases. Satting 94-97% on\n 3-4L NC and 35% humidified FT for comfort. Weak cough, able to raise\n secretions w/encouragement. No NT suctioning required, pt. able to\n raise secretions to back of throat and sxn w/yankauer. Abdomen softly\n distended, hypo BS. No n/v. Incision OTA, intact. Condom cath draining\n large amounts clear yellow urine. Mildly disoriented upon waking but\n easily reorients.\n Action:\n Labs drawn after episode of ? vtach, given 2grams Calcium and Mag 2g.\n Encouraged to cough and deep breathe, assisted w/use of yankauer to sxn\n back to throat for raised secretions. Pt. allowed to sleep in long naps\n overnight as resp. status much improved s/p lasix given upon admit.\n Safety precautions.\n Response:\n No further episodes VT , resp. status improved, great HUO.\n Plan:\n Cont. to monitor lytes, resp. status, cards consulting for AICD\n settings, encourage increased activity and pulm hygiene, cont. per\n current plan of care, ? tx back to 9 today.\n" }, { "category": "Nursing", "chartdate": "2116-01-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 401411, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs diminished bil at bases and coarse upper lobes. O2 sat improved\n throughout day; being able to remove face tent and just use NC. Pt\n using IS and encouraged to CDB. OOB to chair and ambulated in unit.\n Action:\n Surgical team aware of improved respire function and ambulation.\n Response:\n Pt to remain over night in SICU for observation.\n Plan:\n Continue OOB activity, encourage to use IS and to CDB. Monitor pain\n and medicate as ordered. Continue to offer pt and pt family emotional\n support throughout hospital stay. Transfer back to 9 .\n" }, { "category": "Nursing", "chartdate": "2116-01-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 401412, "text": "86y M p/w severe abdominal pain, n/v found to have high-grade SBO with\n potential internal hernia on abdominal CT scan. He was managed\n conservatively initially with NGT decompression and serial abdominal\n exams. The following day began to complain of increasing abdominal pain\n and was focally tender with guarding in RLQ. Pt was taken to the OR for\n ex-lap and lysis of adhesions on . Post-operatively in PACU,\n noted to have WCT at rate of ~ 170 (SVT with aberrancy vs VT)with\n associated drop in SBP to 60s. Broke spontaneously and did not receive\n ICD shock. EP interrogated the device which was reportedly functioning\n appropriately. Pt then admitted to floors. Hospital course c/b episode\n of AMS resolved with prn haldol; bilious emesis with subsequent NGT\n placement with copious bilious outpt. Pt also with low UOP requiring\n several IVF boluses on the floors. On , pt with respiratory\n distress and copious secretions. Pt transferred to the SICU for further\n management.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n BOWEL OBSTRUCTION\n Code status:\n Height:\n Admission weight:\n 84.8 kg\n Daily weight:\n 86.2 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: CAD, Hypertension, MI\n Additional history: spinal stenosis and radiculopathy, internal\n hemoorhoids (bleeding on anoscopy in ), hyperplastic polyps and\n diverticulosis, chf,\n AICD placememt\n hyperlipidemia\n baseline Cr 1.4, hypothyroidism, TIA's, IBS, BPH, s/p cataract surgery\n R eye, secondray hyperparathyroidism\n Surgery / Procedure and date: s/p ex lap with SBO\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:140\n D:64\n Temperature:\n 97.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 66 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Face tent\n O2 saturation:\n 95% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 70% %\n 24h total in:\n 182 mL\n 24h total out:\n 2,670 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 03:16 AM\n Potassium:\n 4.4 mEq/L\n 03:16 AM\n Chloride:\n 102 mEq/L\n 03:16 AM\n CO2:\n 32 mEq/L\n 03:16 AM\n BUN:\n 18 mg/dL\n 03:16 AM\n Creatinine:\n 1.3 mg/dL\n 03:16 AM\n Glucose:\n 88 mg/dL\n 03:16 AM\n Hematocrit:\n 33.4 %\n 03:16 AM\n Finger Stick Glucose:\n 84\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs diminished bil at bases and coarse upper lobes. O2 sat improved\n throughout day; being able to remove face tent and just use NC. Pt\n using IS and encouraged to CDB. OOB to chair and ambulated in unit.\n Action:\n Surgical team aware of improved respire function and ambulation.\n Response:\n Pt to remain over night in SICU for observation.\n Plan:\n Continue OOB activity, encourage to use IS and to CDB. Monitor pain\n and medicate as ordered. Continue to offer pt and pt family emotional\n support throughout hospital stay. Transfer back to 9 .\n" }, { "category": "Physician ", "chartdate": "2116-01-06 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 401311, "text": "TITLE:\n Chief Complaint: respiratory distress\n HPI:\n 86y M p/w severe abdominal pain, n/v found to have high-grade SBO with\n potential internal hernia on abdominal CT scan. He was managed\n conservatively initially with NGT decompression and serial abdominal\n exams. The following day began to complain of increasing abdominal pain\n and was focally tender with guarding in RLQ. Pt was taken to the OR for\n ex-lap and lysis of adhesions on . Post-operatively in PACU,\n noted to have WCT at rate of ~ 170 (SVT with aberrancy vs VT)with\n associated drop in SBP to 60s. Broke spontaneously and did not receive\n ICD shock. EP interrogated the device which was reportedly functioning\n appropriately. Pt then admitted to floors. Hospital course c/b episode\n of AMS resolved with prn haldol; bilious emesis with subsequent NGT\n placement with copious bilious outpt. Pt also with low UOP requiring\n several IVF boluses on the floors. On , pt with respiratory\n distress and copious secretions. Pt transferred to the SICU for further\n management.\n Other medications:\n 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing Order date:\n @ 1700\n 9. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1517\n 2. Calcitriol 0.25 mcg IV DAILY Order date: @ 1521\n 10. Levothyroxine Sodium 62.5 mcg IV DAILY Order date: @ 1521\n 3. Calcium Gluconate IV Sliding Scale Order date: @ 1636\n 11. Magnesium Sulfate IV Sliding Scale Order date: @ 1636\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1517\n 12. Metoprolol Tartrate 5 mg IV Q4H Order date: @ 1517\n 5. Dipyridamole-Aspirin 1 CAP PO BID Order date: @ 1700\n 13. Morphine Sulfate 1-2 mg IV Q4H:PRN pain Order date: @ 1700\n 6. Furosemide 40 mg IV ONCE Duration: 1 Doses Order date: @ 1435\n 14. Pantoprazole 40 mg IV Q24H Order date: @ 1700\n 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 1517\n 15. Potassium Chloride IV Sliding Scale Order date: @ 1636\n 8. Heparin 5000 UNIT SC TID Order date: @ 1629\n 16. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1636\n Post operative day:\n Allergies:\n Penicillins\n Unknown;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:45 PM\n Metoprolol - 03:56 PM\n Heparin Sodium (Prophylaxis) - 04:58 PM\n Past medical history:\n Family / Social history:\n -- CAD s/p MI x2, RCA stent \n -- s/p AICD placement in (due to NSVT and inducible\n monomorphic VT)\n -- HTN\n -- CHF (EF 55% in with diastolic dysfunction)\n -- DM2\n -- hyperlipidemia\n -- history of TIAs\n -- h/o internal hemorrhoids (bleeding on anoscopy in )\n -- colonoscopy in with hyperplastic polyp and diverticulosis\n -- irritable bowel syndrome,\n -- prostate CA s/p TURP ('s) and radiation proctitis\n -- BPH\n -- CKD\n -- hyperparathyroidism\n -- hypothyroidism\n -- s/p cataract surgery R eye\n -- h/o spinal stenosis and radiculopathy\n SOCIAL HISTORY:\n Lives in alone, wife passed away ealier this year. He\n is a retired businessman, former cigar smoker > 10y\n ago, denies EtOH.\n FAMILY HISTORY:\n Father died of emphysema. Mother died of complications from\n hypertension. brother died of \"heart disease\".\n Flowsheet Data as of 05:11 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 74 (74 - 91) bpm\n BP: 148/78(92) {145/66(92) - 155/78(94)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6 mL\n PO:\n TF:\n IVF:\n 6 mL\n Blood products:\n Total out:\n 0 mL\n 730 mL\n Urine:\n 730 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -725 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n early sys murmur at base and apex.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n [image002.jpg]\n Imaging: CXR - decrease in the pulmonary vascular congestion with\n persistent bibasilar atelectasis. Increasing opacification at the left\n base could reflect worsening atelectasis or increasing pleural\n effusion.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment And Plan: 86M with SBO, s/p exlap, LOA now with respiratory\n distress ?aspiration.\n Neurologic: -- AOx3, no focal deficits\n -- consider prn haldol if patient becomes agitated/confused\n -- morphine prn pain\n Cardiovascular: -- hx of MI, CAD, NSVT s/p AICD, CHF\n -- on carvedilol at home. Currently on metoprolol 5mg IV q4h (until can\n resume po meds)\n -- cont aggrenox\n Pulmonary: -- respiratory distress with copious secretions. ?aspiration\n -- encourage Chest PT, IS\n -- likely with pulm effusions. Given lasix 40mg IV x1 to diurese.\n -- albuterol prn\n Gastrointestinal: -- +flatus\n -- NGT d/c'ed \n -- Official S&S consulted. (Bedside swallow, pt appears to be\n aspirating)\n -- PPI for GI prophy\n Renal: -- -- hx of CKD, BPH, prostate CA s/p TURP\n -- condom cath in place. Monitor UOP. Cr 1.2.\n -- (If pt required foley catheter, 14f cudet catheter used in past)\n Hematology: -- Hct 36.8\n Infectious Disease: -- Afebrile. No ABX at this time.\n Endocrine: -- hx of DM: RISS. Restart home meds when tolerating po diet\n -- hx of hypothyroidism: cont levothyroxine\n -- hx of hyperparathyroidism secondary to CKD: cont calcitriol\n Fluids: -- heplocked\n Electrolytes: -- monitor and replete as needed\n Nutrition: -- may take sips once eval'ed by S&S\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:29 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2116-01-07 00:00:00.000", "description": "Intensivist Note", "row_id": 401414, "text": "TITLE:\n SICU\n HPI:\n 86y M p/w severe abdominal pain, n/v found to have high-grade SBO with\n potential internal hernia on abdominal CT scan. He was managed\n conservatively initially with NGT decompression and serial abdominal\n exams. The following day began to complain of increasing abdominal pain\n and was focally tender with guarding in RLQ. Pt was taken to the OR for\n ex-lap and lysis of adhesions on . Post-operatively in PACU,\n noted to have WCT at rate of ~ 170 (SVT with aberrancy vs VT) with\n associated drop in SBP to 60s. Broke spontaneously and did not receive\n ICD shock. EP interrogated the device which was reportedly functioning\n appropriately. Pt then admitted to floors. Hospital course c/b episode\n of AMS resolved with prn haldol; bilious emesis with subsequent NGT\n placement with copious bilious outpt. Pt also with low UOP requiring\n several IVF boluses on the floors. On , pt with respiratory\n distress and copious secretions. Pt transferred to the SICU for further\n management.\n Chief complaint:\n respiratory distress\n PMHx:\n -- CAD s/p MI x2, RCA stent \n -- s/p AICD placement in (due to NSVT and inducible\n monomorphic VT)\n -- HTN\n -- CHF (EF 55% in with diastolic dysfunction)\n -- DM2\n -- hyperlipidemia\n -- history of TIAs\n -- h/o internal hemorrhoids (bleeding on anoscopy in )\n -- colonoscopy in with hyperplastic polyp and diverticulosis\n -- irritable bowel syndrome,\n -- prostate CA s/p TURP ('s) and radiation proctitis\n -- BPH\n -- CKD\n -- hyperparathyroidism\n -- hypothyroidism\n -- s/p cataract surgery R eye\n -- h/o spinal stenosis and radiculopathy\n Current medications:\n 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing Order date:\n @ 1700\n 9. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1517\n 2. Calcium Gluconate IV Sliding Scale Order date: @ 1636\n 10. Levothyroxine Sodium 62.5 mcg IV DAILY Order date: @ 1521\n 3. Calcitriol 0.25 mcg IV 3X/WEEK (TU,TH,SA) Order date: @ 1728\n 11. Magnesium Sulfate IV Sliding Scale Order date: @ 1636\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1517\n 12. Metoprolol Tartrate 5 mg IV Q4H Order date: @ 1517\n 5. Dipyridamole-Aspirin 1 CAP PO BID Order date: @ 1700\n 13. Morphine Sulfate 1-2 mg IV Q4H:PRN pain Order date: @ 1700\n 6. Furosemide 40 mg IV ONCE Duration: 1 Doses Order date: @ 1435\n 14. Pantoprazole 40 mg IV Q24H Order date: @ 1700\n 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 1517\n 15. Potassium Chloride IV Sliding Scale Order date: @ 1636\n 8. Heparin 5000 UNIT SC TID Order date: @ 1629\n 16. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1636\n 24 Hour Events:\n respiratory distress. ?aspiration. Transferred to SICU. s/p aggressive\n suctioning. Given lasix 40mg IV x1. +flatus. NGT removed. Occassional\n runs of NSVT without effect on SBP, asymptomatic. Electrolytes checked\n and repleted as needed.\n Allergies:\n Penicillins\n Unknown;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:45 PM\n Pantoprazole (Protonix) - 08:11 PM\n Heparin Sodium (Prophylaxis) - 12:43 AM\n Morphine Sulfate - 03:00 AM\n Metoprolol - 04:28 AM\n Other medications:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98\n T current: 36.7\nC (98\n HR: 62 (61 - 91) bpm\n BP: 132/62(80) {108/47(60) - 155/79(94)} mmHg\n RR: 16 (13 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.2 kg (admission): 84.8 kg\n Total In:\n 145 mL\n 134 mL\n PO:\n Tube feeding:\n IV Fluid:\n 145 mL\n 134 mL\n Blood products:\n Total out:\n 2,570 mL\n 1,100 mL\n Urine:\n 2,570 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,425 mL\n -966 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: ///32/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 231 K/uL\n 11.0 g/dL\n 88 mg/dL\n 1.3 mg/dL\n 32 mEq/L\n 4.4 mEq/L\n 18 mg/dL\n 102 mEq/L\n 142 mEq/L\n 33.4 %\n 10.4 K/uL\n [image002.jpg]\n 10:00 PM\n 03:16 AM\n WBC\n 10.4\n Hct\n 33.4\n Plt\n 231\n Creatinine\n 1.2\n 1.3\n Glucose\n 87\n 88\n Other labs: Ca:8.9 mg/dL, Mg:2.8 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR - decrease in the pulmonary vascular congestion with\n persistent bibasilar atelectasis. Increasing opacification at the left\n base could reflect worsening atelectasis or increasing pleural\n effusion.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ASSESSMENT: 86M with SBO, s/p exlap, admit to ICU with resp distress,\n now much improved ?aspiration due to hx of vomiting on floor.\n Neurologic:\n -- AOx3, no focal deficits\n -- consider prn haldol if patient becomes agitated/confused\n -- morphine prn pain\n Cardiovascular:\n -- hx of MI, CAD, self terminated NSVT s/p AICD, CHF\n -- on carvedilol at home. Currently on metoprolol 5mg IV q4h (until can\n resume po meds)\n -- cont aggrenox\n -- occassional episodes of NSVT. Electrolytes checked and repleted as\n needed.\n -- EP to report if SVT is new onset or unchanged from preop\n f/u with\n interrogation of device.\n Pulmonary:\n -- respiratory distress with copious secretions. ?aspiration\n -- encourage Chest PT, IS\n -- likely with pulm effusions. Given lasix 40mg IV x1 to diurese.\n -- albuterol prn\n Subjectively improved\n Gastrointestinal / Abdomen:\n -- +flatus\n -- NGT d/c'ed \n -- Official S&S consulted. (Bedside swallow, pt appears to be\n aspirating)\n -- PPI for GI prophy\n Nutrition: may take sips once eval'ed by S&S\n Dobhoff if doesn\nt pass S&S\n Renal:\n -- hx of CKD, BPH, prostate CA s/p TURP\n -- condom cath in place. Monitor UOP. Cr 1.3.\n -- (If pt required foley catheter, 14f cudet catheter used in past)\n Hematology:\n -- Hct 33.4\n Endocrine:\n -- hx of DM: RISS. Restart home meds when tolerating po diet\n -- hx of hypothyroidism: cont levothyroxine\n -- hx of hyperparathyroidism secondary to CKD: cont calcitriol\n ID: Afebrile. No ABX at this time. WBC 10.4\n T/L/D: PIVx1, condom cath (consider PICC?)\n Wounds: abdominal incision c/d/i\n Imaging: CXR\n Fluids: heplocked\n Consults: gold west 2 surgery, cardiology\n Billing Diagnosis: respiratory distress\n Prophylaxis:\n DVT: aggrenox, SQH\n Stress ulcer: PPI\n VAP bundle: n/a\n Comments: ICU consent completed\n Communication: Son (h), (w),\n (c), (c)\n Code status:FULL\n Disposition:Floor\n Time spent: 35\n" }, { "category": "Physician ", "chartdate": "2116-01-06 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 401294, "text": "TITLE:\n Chief Complaint: respiratory distress\n HPI:\n 86y M p/w severe abdominal pain, n/v found to have high-grade SBO with\n potential internal hernia on abdominal CT scan. He was managed\n conservatively initially with NGT decompression and serial abdominal\n exams. The following day began to complain of increasing abdominal pain\n and was focally tender with guarding in RLQ. Pt was taken to the OR for\n ex-lap and lysis of adhesions on . Post-operatively in PACU,\n noted to have WCT at rate of ~ 170 (SVT with aberrancy vs VT)with\n associated drop in SBP to 60s. Broke spontaneously and did not receive\n ICD shock. EP interrogated the device which was reportedly functioning\n appropriately. Pt then admitted to floors. Hospital course c/b episode\n of AMS resolved with prn haldol; bilious emesis with subsequent NGT\n placement with copious bilious outpt. Pt also with low UOP requiring\n several IVF boluses on the floors. On , pt with respiratory\n distress and copious secretions. Pt transferred to the SICU for further\n management.\n Other medications:\n 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing Order date:\n @ 1700\n 9. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1517\n 2. Calcitriol 0.25 mcg IV DAILY Order date: @ 1521\n 10. Levothyroxine Sodium 62.5 mcg IV DAILY Order date: @ 1521\n 3. Calcium Gluconate IV Sliding Scale Order date: @ 1636\n 11. Magnesium Sulfate IV Sliding Scale Order date: @ 1636\n 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: \n @ 1517\n 12. Metoprolol Tartrate 5 mg IV Q4H Order date: @ 1517\n 5. Dipyridamole-Aspirin 1 CAP PO BID Order date: @ 1700\n 13. Morphine Sulfate 1-2 mg IV Q4H:PRN pain Order date: @ 1700\n 6. Furosemide 40 mg IV ONCE Duration: 1 Doses Order date: @ 1435\n 14. Pantoprazole 40 mg IV Q24H Order date: @ 1700\n 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date: \n @ 1517\n 15. Potassium Chloride IV Sliding Scale Order date: @ 1636\n 8. Heparin 5000 UNIT SC TID Order date: @ 1629\n 16. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1636\n Post operative day:\n Allergies:\n Penicillins\n Unknown;\n Plavix (Oral) (Clopidogrel Bisulfate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 02:45 PM\n Metoprolol - 03:56 PM\n Heparin Sodium (Prophylaxis) - 04:58 PM\n Past medical history:\n Family / Social history:\n -- CAD s/p MI x2, RCA stent \n -- s/p AICD placement in (due to NSVT and inducible\n monomorphic VT)\n -- HTN\n -- CHF (EF 55% in with diastolic dysfunction)\n -- DM2\n -- hyperlipidemia\n -- history of TIAs\n -- h/o internal hemorrhoids (bleeding on anoscopy in )\n -- colonoscopy in with hyperplastic polyp and diverticulosis\n -- irritable bowel syndrome,\n -- prostate CA s/p TURP ('s) and radiation proctitis\n -- BPH\n -- CKD\n -- hyperparathyroidism\n -- hypothyroidism\n -- s/p cataract surgery R eye\n -- h/o spinal stenosis and radiculopathy\n SOCIAL HISTORY:\n Lives in alone, wife passed away ealier this year. He\n is a retired businessman, former cigar smoker > 10y\n ago, denies EtOH.\n FAMILY HISTORY:\n Father died of emphysema. Mother died of complications from\n hypertension. brother died of \"heart disease\".\n Flowsheet Data as of 05:11 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 74 (74 - 91) bpm\n BP: 148/78(92) {145/66(92) - 155/78(94)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6 mL\n PO:\n TF:\n IVF:\n 6 mL\n Blood products:\n Total out:\n 0 mL\n 730 mL\n Urine:\n 730 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -725 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n early sys murmur at base and apex.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n [image002.jpg]\n Imaging: CXR - decrease in the pulmonary vascular congestion with\n persistent bibasilar atelectasis. Increasing opacification at the left\n base could reflect worsening atelectasis or increasing pleural\n effusion.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment And Plan: 86M with SBO, s/p exlap, LOA now with respiratory\n distress ?aspiration.\n Neurologic: -- AOx3, no focal deficits\n -- consider prn haldol if patient becomes agitated/confused\n -- morphine prn pain\n Cardiovascular: -- hx of MI, CAD, NSVT s/p AICD, CHF\n -- on carvedilol at home. Currently on metoprolol 5mg IV q4h (until can\n resume po meds)\n -- cont aggrenox\n Pulmonary: -- respiratory distress with copious secretions. ?aspiration\n -- encourage Chest PT, IS\n -- likely with pulm effusions. Given lasix 40mg IV x1 to diurese.\n -- albuterol prn\n Gastrointestinal: -- +flatus\n -- NGT d/c'ed \n -- Official S&S consulted. (Bedside swallow, pt appears to be\n aspirating)\n -- PPI for GI prophy\n Renal: -- -- hx of CKD, BPH, prostate CA s/p TURP\n -- condom cath in place. Monitor UOP. Cr 1.2.\n -- (If pt required foley catheter, 14f cudet catheter used in past)\n Hematology: -- Hct 36.8\n Infectious Disease: -- Afebrile. No ABX at this time.\n Endocrine: -- hx of DM: RISS. Restart home meds when tolerating po diet\n -- hx of hypothyroidism: cont levothyroxine\n -- hx of hyperparathyroidism secondary to CKD: cont calcitriol\n Fluids: -- heplocked\n Electrolytes: -- monitor and replete as needed\n Nutrition: -- may take sips once eval'ed by S&S\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:29 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2116-01-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 401397, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs diminished bil at bases and coarse upper lobes. O2 sat improved\n throughout day; being able to remove face tent and just use NC. Pt\n using IS and encouraged to CDB. OOB to chair and ambulated in unit.\n Action:\n Surgical team aware of improved respire function and ambulation.\n Response:\n Pt to remain over night in SICu for observation.\n Plan:\n Continue OOB activity, encourage to use IS and to CDB. Monitor pain\n and medicate as ordered. Continue to offer pt and pt family emotional\n support throughout hospital stay. Transfer back to 9 .\n" }, { "category": "Radiology", "chartdate": "2116-01-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1121602, "text": " 4:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval effusions vs pna\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with increased secretions\n REASON FOR THIS EXAMINATION:\n eval effusions vs pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increased secretions, evaluate for pneumonia.\n\n FINDINGS: In comparison with the study of , the patient has taken a\n somewhat better inspiration. Enlargement of the cardiac silhouette persists\n in a patient with a dual-channel pacemaker device in place. Bibasilar\n atelectasis is again seen without definite effusion. The nasogastric tube has\n been removed.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1121511, "text": " 10:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA, edema, effusion\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p SBR with n/v now with increased respiratory effort\n REASON FOR THIS EXAMINATION:\n ? PNA, edema, effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increased respiratory effort.\n\n FINDINGS: In comparison with study of , there is decrease in the\n pulmonary vascular congestion with persistent bibasilar atelectasis.\n Increasing opacification at the left base could reflect worsening atelectasis\n or increasing pleural effusion.\n\n Persistent low lung volumes. Nasogastric tube has been inserted with its tip\n in the body of the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1120661, "text": " 7:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval position of NGT (he pulled it)\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with NGT s/p exlap and LOA\n REASON FOR THIS EXAMINATION:\n please eval position of NGT (he pulled it)\n ______________________________________________________________________________\n WET READ: GWp TUE 8:02 PM\n Low lung volumes limit NGT & sidehole project over stomach Bibasal opac\n persist GWlms\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:42 P.M. ON \n\n HISTORY: NG tube placement after abdominal surgery. Evaluate position.\n\n IMPRESSION: AP chest compared to :\n\n Nasogastric tube ends in the stomach, probably up against the greater\n curvature. Transvenous right atrial pacer lead is oriented towards the\n midline in the tricuspid valve, unchanged since , but changed since\n when the positioning was more standard, oriented toward the\n right atrial appendage. Transvenous pacer defibrillator lead follows more\n usual course, projecting over the floor of the right ventricle pointing to the\n cardiac apex.\n\n Small left pleural effusion is new, moderate bibasilar atelectasis stable on\n the right, increased on the left. No pneumothorax. Upper lobes clear. Dr.\n was paged to discuss these findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-01-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1120895, "text": " 8:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess consolidation, PNA\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with desaturation\n REASON FOR THIS EXAMINATION:\n assess consolidation, PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man with desaturation. Assess for consolidation.\n\n COMPARISON: Multiple priors, most recent portable AP chest radiograph\n .\n\n TECHNIQUE: Portable AP chest radiograph.\n\n FINDINGS: The nasogastric tube has been removed since .\n Left-sided pacer device is present with leads projecting over the region of\n the right atrium and right ventricle. Tip of right ventricular pacer lead is\n not included in the image. Cardiac, mediastinal, and hilar contours are\n stable since with mild cardiomegaly. Left costophrenic angle\n is not included within the image, however, left-sided pleural effusion noted\n on is unchanged. Low lung volumes are once again noted.\n Moderate bibasilar atelectasis is improved on the right side and is stable on\n the left. Mild pulmonary edema is worsening since . There is\n no pneumothorax.\n\n IMPRESSION:\n 1. Mild pulmonary edema is worsening since .\n 2. Moderate bibasilar atelectasis is improved in the right and stable on the\n left.\n 3. Left-sided pleural effusion is unchanged since .\n\n" }, { "category": "Radiology", "chartdate": "2115-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1120497, "text": " 9:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with hypoxia, SBO\n REASON FOR THIS EXAMINATION:\n ?aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 86-year-old male with hypoxia. Evaluate for\n aspiration.\n\n EXAMINATION: Single frontal chest radiograph.\n\n COMPARISONS: Comparison is made to .\n\n FINDINGS: There is bibasilar right greater than left atelectasis. Worsening\n of elevation of the right hemidiaphragm may be compounded by atelectasis. The\n remainder of the lungs remain clear without definite consolidation, pleural\n effusion, or evidence of pneumothorax. Nasogastric tube is seen coursing\n below the diaphragm. The patient is noted to be status post dual-chamber\n AICD/PPM. Stable cardiomediastinal contours demonstrating atherosclerotic\n calcification of the aorta and left ventricular configuration of the heart.\n Stable cardiomegaly.\n\n IMPRESSION:\n 1. Bibasilar right greater than left atelectasis without definite\n superimposed pneumonia.\n\n 2. Nasogastric tube seen coursing below the diaphragm.\n\n" }, { "category": "Radiology", "chartdate": "2116-01-03 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1121201, "text": " 8:36 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ileus vs obstruction, gastric distention\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p SBO with LOA now with n/v\n REASON FOR THIS EXAMINATION:\n ileus vs obstruction, gastric distention\n ______________________________________________________________________________\n FINAL REPORT\n RADIOGRAPHS OF THE ABDOMEN\n\n CLINICAL INDICATION: 86-year-old man status post SBO with LOA, now with\n nausea and vomiting. Rule out ileus versus obstruction.\n\n COMPARISON EXAM: CT scan on .\n\n FINDINGS:\n\n Supine films only. cannot assess for free air or air fluid levels.\n Nasogastric tube with tip seen in the stomach. Biventricular pacemaker leads\n are seen. There is moderate, diffuse distention of the small bowel,\n measuring maximally to 4.1 cm. There is gas seen distally within the rectum,\n with air seen within several loops of colon. There are midline surgical\n staples within the lower pelvis, with surgical clips in the lower pelvis. Lung\n bases are clear. Note is made of extensive vascular calcification. No portal\n venous gas or pneumatosis is seen.\n\n IMPRESSION:\n\n 1. Diffuse small bowel distention with gas seen within the colon and rectum,\n This is a nonspecific pattern. Recommend follow-up.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-30 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1120475, "text": " 5:40 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?diverticulitis, colitis, obstruction\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with diffuse TTP in abd\n REASON FOR THIS EXAMINATION:\n ?diverticulitis, colitis, obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RBLd MON 8:48 PM\n High grade SBO with TP in RLQ (coronal 301b:Im26) with possible additional TP\n in RLQ. Subtle swirling of mesentery and abnormal configuration of some loops\n of small bowel raises concern for internal hernia. mesenteric haziness. RLQ\n free fluid. Early ishemia can not be excluded. Colon almost completely\n decompressed. Fluid distended stomach with collapsed duodenum, may be due to\n gastric outlet obtruction.\n Inc in size infrarenal AAA, measures 3.2 cm (2.8 cm ) and right\n internal iliac aneurysm, 3.3 cm (2.5cm ). right comm iliac artery\n aneurysm= 1.5 cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 86-year-old male with diffuse tenderness to\n palpation in the abdomen. Evaluate for diverticulitis, colitis or\n obstruction.\n\n EXAMINATION: CT of the abdomen and pelvis with intravenous contrast.\n\n COMPARISONS: Comparison is made to examination from and .\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the pubic symphysis after the administration of 100 cc of Visipaque\n intravenous contrast only. Coronal and sagittal reformations were obtained.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:\n\n There is bibasilar, right greater than left, bronchiectasis and\n scarring/fibrosis with interstitial reticulation that could be either related\n to chronic inflammation/infection. No pleural effusions or pulmonary nodules.\n\n There is extensive atherosclerotic calcification involving the coronary\n arteries and valvular calcification.\n\n The liver, gallbladder, spleen, pancreas, both adrenal glands are\n unremarkable. Note is made of a prominent fluid-filled stomach with\n associated collapse of the duodenum that maybe related to a component of\n gastric outlet obstruction. Both kidneys are atrophic in nature.\n\n There is extensive atherosclerotic calcification involving the abdominal aorta\n and its major branches. There has been interval increase in size since prior\n (Over)\n\n 5:40 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?diverticulitis, colitis, obstruction\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n examinations of of an infrarenal abdominal aortic aneurysm that now\n measures 3.2 cm in transverse diameter where it measured 2.8 in . In\n addition, there is ectasia of the right common iliac artery measuring up to\n 1.5 cm and a more focal right internal iliac aneurysm measuring up to 3.3 cm,\n increased from 2.5 cm in .\n\n There is no intra-abdominal free air. There are prominent fluid-filled loops\n of small bowel measuring up to 3.4 cm. There is new acute complete\n decompression of the colon with only minimal retained fecal matter seen within\n the cecum. In addition, the terminal ileum appears to be decompressed.\n Overall, the findings are most compatible with high-grade small-bowel\n obstruction. One transition point for this high-grade obstruction is seen\n within the right lower quadrant (series 301b:26). There maybe a second\n additional transition point in the right lower quadrant. Subtle swirling of\n the mesentery and a abnormal configuration of several of the small bowel loops\n raises the concern for internal hernia. There is associated mesenteric\n haziness and right lower quadrant free fluid that could be related to\n congestion, though early ischemia cannot be excluded. There is no evidence of\n pneumatosis. There is no evidence of bowel wall thickening.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The colon is almost completely\n decompressed with minimal retained fecal material and small amount of air in\n the cecum. There is sigmoid diverticulosis without evidence of diverticulitis.\n The patient is noted to be status post prostatectomy. Multiple bilateral\n pelvic side wall surgical clips are noted. The bladder is unremarkable. The\n rectum is decompressed though unremarkable in appearance. There is a small\n amount of pelvic free fluid. There is no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: There are extensive degenerative changes of the thoracolumbar\n spine. There is grade 1 retrolisthesis of the L3 on L4 and L4 on L5 vertebral\n bodies. Vacuum phenomenon seen at multiple levels. No suspicious lytic or\n sclerotic foci.\n\n IMPRESSION:\n 1. Dilated fluid-filled loops of small bowel measuring up to 3.4 cm with\n decompressed colon and terminal ileum consistent with high- grade small-bowel\n obstruction. One definite transition point seen within the right lower\n quadrant (301b:26); however, a second transition point may also be prsent\n within the right lower quadrant. Suggestion of swirling of the mesentery and\n abnormal configuration of small bowel loops raises the possibility of internal\n hernia. Associated small amount of right lower quadrant and pelvic free fluid\n along with mesenteric stranding specifically in the right lower quadrant could\n be related to congestive change, although early ischemia is not excluded.\n\n 2. Interval increase in size of infrarenal abdominal aortic aneurysm, now\n measuring 3.4 cm where on it measured up to 2.8 cm. Increased right\n (Over)\n\n 5:40 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?diverticulitis, colitis, obstruction\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n internal iliac aneurysm measuring 3.3 cm (measured 2.5cm in ). Ectasia of\n the right common iliac artery measuring up to 1.5 cm.\n\n 3. Diverticulosis without secondary signs of diverticulitis.\n\n 4. Bronchiectasis and reticulation could relate to chronic\n inflammatory/infectious changes within the bilateral lung bases.\n\n\n The above findings were submitted to the emergency department via electronic\n wet read at 8:48 PM on and discussed with Dr. ,\n surgery, just prior to the wet read placement.\n\n\n" } ]